12. We have set out our decision under subheadings below, for clarity. However, given the overlapping nature of some of the issues we have looked at, some of the issues below are not in a chronological order.
MYTT: Treatment upon admission
13. Mrs Z complains MYTT did not treat Mr Z’s condition as urgent when he was admitted to hospital on 11 July 2022. He reported feeling unwell for several weeks, losing a stone in weight and a loss of appetite. He also reported feeling dizzy, tired, and difficulty breathing. We can see Mr Z was admitted to hospital via A&E and placed under the care of the surgical team. There was suspicion that there was a serious underlying condition causing his symptoms, such as cancer.
14. NICE’s ‘NG12: Suspected cancer: recognition and referral’ outlines the recommendations for non-specific symptoms of suspected cancer from the perspective of a primary care giver, such as a GP. Our physician adviser told this is the applicable guideline because Mr Z had non-specific symptoms of cancer but was presenting as unwell, and staff in the hospital suspected the symptoms to be because of cancer. This guidance sets out two different timescales for carrying out investigations into suspected cancer. The timescale applicable is dependent on the symptoms being presented.
15. The first timescale applies if a person is referred by their GP for investigations. The guidance says a person should receive a diagnosis or ruling out of cancer within 28 days of the referral. The other timescale is that urgent investigations are commenced, and they should happen or be completed within two weeks.
16. We can see Mr Z was investigated promptly after he was admitted on 11 July. A CT scan of his abdomen, thorax, and pelvis was performed on 12 July and a liver biopsy was performed on 15 July. This is within the timescales set out in the guidance quoted above. Therefore, we consider there to be no failing with regard to this issue.
MYTT: Suspected cancer discussion
17. Mrs Z says MYTT failed to involve her in the discussion with Mr Z on 11 July when he was told it was suspected he had cancer. She says Mr Z was shocked by the information and it had upset him. This, in turn, upset her as she was unable to offer him support at the time. In Mrs Z’s complaint to MYTT, her concerns focused on 13 July rather than 11 July as she claimed to us. As such, we have considered the communication around this time, as a whole.
18. The GMC’s ‘Good Medical Practice’ provides guidance for clinicians about communicating with patients and their families and recording these discussions in clinical records. It says doctors must:
• Listen to patients, take account of their views, and response honestly to their questions.
• Give patients the information they want or need to know in a way they can understand.
• Make plans wherever possible to meet patients’ language and communication needs.
• Be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
• Clearly, accurately, and legibly document in a patient’s clinical records the information given to patients.
19. On 11 July, as mentioned in the previous section, staff suspected cancer after they assessed Mr Z. However, it is not documented in the clinical records what discussion took place with Mr and Mrs Z. We only know Mr Z was told of his suspected diagnosis because this is what Mrs Z has told us. However, while it appears she was present at the assessment, she was not present when Mr Z was told about what staff suspected. Again, this is because this is what she tells us, and there is no other evidence available that disputes her account.
20. On 12 July, Mr Z underwent a surgical review, and Mrs Z was not present. Again, it is noted that cancer was suspected, and this was documented as being cancer of the biliary system. This is the network of organs and ducts that produce, store, secrete, and transport bile which is a digestive fluid made by the liver. The biliary system is made up of the liver, gallbladder, and bile ducts. However, it is not documented whether this was communicated to Mr Z, or how much information he was given at all about next steps.
21. Our physician adviser told us you would expect staff to have told Mr Z what investigations were planned and why. They told us this discussion would also typically include a discussion about the possibility of cancer, and questions about how Mr Z would want to receive serious or distressing information when his results became available.
22. Over subsequent days, we can see brief references to a discussion with Mr Z about the suspected cancer and the need for further assessment, including MDT discussion, and a liver biopsy. There is also reference to information to be provided to Mrs Z. However, there is no detail about these discussions, so it is not possible for us to say whether the information provided at this stage was appropriate.
23. Therefore, we consider this to be a failing. This is because we cannot see that MYTT staff had detailed discussions with Mr and Mrs Z, in line with the GMC’s ‘Good Medical Practice’. Next, we considered the likely impact of this.
Impact
24. Mrs Z has told us how Mr Z felt that staff who were supposed to be caring for him acted like he did not matter. This was distressing and upsetting for them both. As outlined above, we know Mr Z was told that the Trust suspected cancer because that is what Mrs Z has told us and, at times, there are brief references to this in the clinical records.
25. However, Mrs Z has told us she and Mr Z were unclear on what would happen next and how serious Mr Z’s cancer was. Taking this into account and the lack of detail in the notes in which it was mentioned that discussions were had, we recognise it was more likely than not that both were unclear at the time of events, especially earlier on in their experience. We consider this would have been confusing and upsetting for them both and it would have compounded the already very prevalent worries they would have been experiencing. We make recommendations later to address this.
MYTT: Endoscopy
26. Mrs Z complains MYTT failed to carry out an endoscopy in July 2022 despite originally planning to do so. Mrs Z is concerned that not carrying out this procedure after initially planning to do so could indicate mistakes were made.
27. An endoscopy is a procedure used to look inside the body. A colonoscopy and sigmoidoscopy are both commonly known types of endoscopy. They help doctors view organs inside the body without making standard surgical incisions using a thin tube with a small camera attached to one end.
28. From the clinical records available we can see an endoscopy (and a colonoscopy) were considered as being necessary during the initial investigations Mr Z underwent to determine the type of cancer he had. However, after a discussion with a specialist radiologist on 13 July, it was decided that the best course of action would be to perform an ultrasound guided liver biopsy instead. This is a medical procedure that combines the use of ultrasound imaging with a needle to obtain tissue samples from an abnormal area of the body, to determine what the abnormality is.
29. Once this decision was made, there was no longer a need for an endoscopy, or colonoscopy, to be carried out. Our physician adviser told us the ultrasound guided liver biopsy, on top of the other investigations (CT scan as mentioned in paragraph 17) were appropriate, and there is no evidence an endoscopy, or colonoscopy, was also required.
30. We consider this to be in line with the GMC’s ‘Good Medical Practice’ which says doctors must arrange for the appropriate investigations that will suit the needs of the patient to be carried out, and should avoid treatments or investigations that are not beneficial. Therefore, we do not consider this to be a failing.
31. We recognise why Mrs Z was concerned that a procedure she thought was due to take place, did not, but we hope we have reassured her that this was not a failing but rather a clinical decision to carry out an alternative investigative procedure.
MYTT: Provision of discharge letters
32. Mrs Z complains MYTT failed to provide discharge letters to Mr Z when he was discharged from hospital on 16 July and 3 August. She says this meant she, Mr Z and his GP were not fully aware of what had happened in hospital, or clear on next steps.
33. We recognise how distressing it will have been for Mr and Mrs Z after Mr Z was discharged and not be sure on what was going to happen next. Particularly given Mr Z’s health at the time, and the concerns they all had about his cancer.
34. NHSE’s ‘Guidance on the NHS Standard Contract requirements on discharge summaries and clinic letters and on interoperability of clinical IT systems’ says a discharge letter should be sent to a patient’s GP within 24 hours. DHSC’s ‘Hospital Discharge and Community Support Guidance’ also says hospital discharge teams should arrange dedicated staff to support and facilitate discharge, including ensuring people have full information about the next steps of their care. They should also be provided with a discharge summary which includes any changes to pre-admission medication.
35. This means we should be able to see evidence MYTT provided discharge information to Mr Z, and to his GP. However, this is not the case. With regard to Mr Z’s discharge on 16 July, no discharge information was provided to him or his GP until 2 September. This was after Mr Z had sadly died. With regard to his discharge on 3 August, we cannot see evidence any discharge letter or information was provided to Mr Z or his GP on the day. MYTT did, however, send a discharge letter to his GP on 5 August. This therefore means MYTT did not act in line with the NHSE and DHSC guidance as set out in paragraph 34. As such, we consider this to be a failing.
36. During the complaints process, MYTT acknowledged it did not provide Mr Z, his GP, or Mrs Z with a discharge letter or information about the admissions and discharge, and it apologised for this. It also explained how it had improved its systems, and reminded doctors and other clinicians about the importance of providing this information promptly, irrespective of other pressures on the service.
37. We have not seen any evidence that these failings led to any avoidable negative clinical impact on Mr Z. For the discharge on 16 July, Mr Z was awaiting the outcome of his biopsy, discussion at MDT, and had anticipatory medication given to him (this is medication prescribed just in case a patient needs it, as part of their end-of-life care). For the discharge on 3 August, Mr Z knew at this point he had metastatic cancer but he had not yet been discussed at the MDT. Therefore, it was not known what treatments or next steps would be. However, this is not because of the lack of discharge information. On that basis, we do not consider there was a clinical impact on Mr Z because of these failings.
38. That said, we recognise the distress and confusion that would have been present, with a specific reference to the distress Mrs Z would have felt upon learning and seeing that discharge information had been sent out after Mr Z had died.
39. Our ‘NHS Complaint Standards’ say organisations should learn from their mistakes and take appropriate action to put things right. This can be a wide range of things from an apology up to a financial remedy and service improvements. In this case, we consider the acknowledgement and apology from MYTT (when coupled with the learning it has taken from the complaint) is enough to put right the impact of these failings. This is because our ‘Severity of Injustice Scale’ says we consider an apology to be enough where the effect on the individual is of short duration and where there are no other adverse effects or ongoing wider impacts. We consider this to be the case here.
MYTT: Nutritional plan
40. Mrs Z complains MYTT failed to put a nutritional plan in place when Mr Z was discharged on 3 August.
41. We can see from the clinical records that in the early hours of 14 July, staff carried out a nutritional screening of Mr Z. Nutritional screening is used to identify individuals at risk of malnutrition, and it helps them guide the appropriate interventions. The outcome of this screening was that Mr Z was at high risk of malnutrition, and staff documented that a referral to a dietician was required. A dietician is a healthcare professional that specializes in nutrition and dietetics. In other words, they assess, diagnose, and treat dietary and nutritional problems.
42. Mr Z was assessed by a dietitian on 15 July. It is noted that Mr Z told the dietitian he had lost around 9kg in the previous three weeks, and that he had a loss of appetite for approximately a month. However, he also reported that his appetite was gradually returning, and that he had eaten a full breakfast and full evening meal recently. The note indicates that the dietitian discussed starting nutritional supplements for Mr Z but he declined this because he felt his oral intake would maintain his weight given the fact his appetite seemed to be improving.
43. Mr Z and the dietitian agreed that his weight would be monitored and if further weight loss occurred, there may be a need for nutritional supplements. The dietitian noted that if Mr Z was discharged before they next saw him, then this would be followed up in an outpatient clinic. Mr Z was discharged a day later.
44. Following a short readmission a few days later due to symptoms attributed to an infection, which were treated with antibiotics, he was reviewed prior to his discharge, on 3 August, and it is noted that he was eating and drinking.
45. Our physician adviser told us there was no requirement to reassess the nutritional plan that had been agreed on 15 July, ahead of the discharge on 3 August. The plan to monitor Mr Z and follow up any changes with clinic follow-up was appropriate.
46. We consider this to be in line with the GMC’s ‘Good Medical Practice’ which says doctors must adequately assess their patients, taking account of their history, views and values, and promptly provide or arrange suitable advice and care. As above, we do not consider there to have been anything during Mr Z’s admission or presentation that the doctor should have identified which would have required a nutritional review. We therefore do not consider there to be failings regarding this aspect of the complaint.
MYTT: MDT referral
47. Mrs Z complains MYTT told Mr Z on 26 July his case would be referred to an MDT meeting for discussion at a local Trust, but the referral was not made until 5 August. She is concerned the delay in the referral had a negative clinical impact on Mr Z.
48. We can see Mr Z’s case was discussed at MYTT’s upper GI MDT on 26 July. The conclusion from this MDT was that Mr Z had a metastatic malignant melanoma. This is a type of skin cancer that has spread from a primary cancerous tumour. The upper GI MDT decided a referral to the melanoma MDT at a local trust was required. This was the plan.
49. However, the referral form was completed and dated 5 August, which was ten days after the upper GI MDT in which the plan was made. MYTT told Mrs Z in its response to her complaint that the referral form it was required to complete to refer Mr Z to the local trust did not arrive until 5 August. It said the consultant completed and returned this form on the same day so the delay was not its own. MYTT told Mrs Z it recognised the difficult time she and Mr Z were having while waiting for the outcome of the MDTs and management plan. It also tried to reassure Mrs Z that the delay would not have changed Mr Z’s outcome.
50. Our physician adviser told us there was a delay (as Mrs Z and MYTT confirmed) but there is no specific guidance relating to the timing of such a referral. That said, it is expected to be made as soon as practicably possible.
51. Sadly, we do not know why it took ten days for the local trust involved to provide the form to MYTT. There is no dispute over the fact it took ten days for the referral to ultimately be made, but the MYTT consultant completed and returned this on the same day.
52. Our physician adviser told us the delay is unlikely to have had any negative clinical impact on Mr Z because at this time, he had an advanced stage of cancer, and he went on to receive palliative care (as we discuss later in this report).
53. We know it will be upsetting for Mrs Z to have learnt that the referral was not made for ten days. We do not think this is a failing by MYTT, but we hope our investigation of this issue, and reassurance that it would not have negatively impacted Mr Z’s care or outcome, is helpful.
MYTT: Palliative care team referral
54. Mrs Z complains MYTT was delayed in referring Mr Z to the palliative care team. She says this delay meant Mr Z was not receiving the appropriate care at the correct time.
55. There is no guidance or standards that say when patients should be referred to a specialist palliative care team. As such, we have referred to the GMC’s ‘Good Medical Practice’ and the NMC’s ‘The Code’.
56. The GMC’s ‘Good Medical Practice’ says doctors must promptly provide or arrange suitable advice, investigations or treatment where necessary. It also says they must refer a patient to another practitioner when this serves the patient’s needs. The NMC’s ‘The Code’ says nurses should respect the skills, expertise, and contributions of their colleagues. They should refer to their colleagues when appropriate, and they should make a timely referral to another practitioner when any action, care, or treatment is required.
57. The clinical records show MYTT referred Mr Z’s case to the palliative care team on 2 August when staff on the ward contacted the palliative care team to obtain advice about the management of his symptoms. Further advice was sought on 3 August about medication and the management of Mr Z’s symptoms, and it is noted he wanted to be discharged that day.
58. A palliative care specialist nurse also noted that ward staff could refer to district nurses (specialised healthcare professionals who provide nursing care to patients in their homes and community settings). It is noted a referral was made to the district nurses to administer medications subcutaneously (when medications are injected into the fat layer beneath the skin with a short needle). The note also says the palliative care team would make a referral to the community teams at a local hospice.
59. Mr Z’s GP saw Mr Z on 4 August, the day after he was discharged. This was to discuss his condition because Mr Z was unclear on the next steps in his treatment and was still feeling unwell. We understand Mr Z’s GP also discussed end-of-life care. We recognise Mr Z (and their GP) were unclear on what the next steps would be at this stage. However, the clinical records also show that all parties were aware Mr Z had metastatic cancer that had spread, but the primary source of this was unknown. The GP agreed to chase up the Trust’s referral to the MDT and to obtain the discharge letter that had not yet been received. On 5 August, Mrs Z also spoke with the hospice’s community team on the phone regarding Mr Z’s condition, and the prescription of anticipatory medication.
60. Our physician and nurse advisers told us the involvement of the palliative care team at this time was appropriate (given Mr Z’s condition and cancer at the time) and not delayed. They told us suitable advice was sought, and Mr Z was referred to other practitioners who could serve his needs.
61. This is what we expect to see when staff are acting in line with the GMC’s ‘Good Medical Practice’ and the NMC’s ‘The Code’.
62. As such, we do not consider there to be a failing with this aspect of the complaint.
MYTT: Palliative care nurse
63. Mrs Z complains that Mr Z’s clinical records show he was under the care of a palliative nurse specialist from 3 August. However, she says she does not know who this was, and that Mr Z never saw them.
64. The clinical records show that Mr Z was under the care of the palliative care team in MYTT (having been referred there as discussed in the previous section) and there were several interactions with them, albeit not directly. It is unclear why Mrs Z is of the view he was under the care of a specific nurse, rather than the overall team, and would therefore have met or spoke to somebody specifically. As mentioned earlier in this report, a referral was made to MYTT’s palliative care team, and they provided advice to the nurses on the ward.
65. When Mr Z was later discharged from MYTT, referrals were made to the hospice and community teams who were responsible for providing care in the community. This is what you would expect to happen. Our nurse adviser told us these teams visited Mr Z promptly and continued to visit him throughout August to provide treatments and palliative care.
66. That said, we can see from the clinical records that when Mr and Mrs Z saw the community teams (whether that was the hospice nurses or district nurses) during August, it is clear they wanted more information about Mr Z’s prognosis because they were unclear on what was happening. However, these nurses were only able to provide general advice about symptom control and provide emotional support. This is because there was still no MDT outcome. While we recognise it is documented in the clinical records that Mr and Mrs Z were told there was ‘nothing further’ MYTT could do for Mr Z, there were clearly gaps in their understanding. We have commented elsewhere in this report about a lack of clear communication with Mr and Mrs Z, so we will not repeat this here.
67. Nonetheless, we can see the advice nurses were giving to Mr and Mrs Z was in line with the NMC’s ‘The Code’. This says nurses must only share information with patients and their families that they want or need to know about their health, care, and ongoing treatment. They must do this sensitively and in a way that can be understood.
68. With this in mind, we do not consider there to be any failings here. The evidence available shows Mr Z received input from MYTT’s palliative care team when he was in hospital and, when he was discharged, the palliative care was provided by the community teams.
MYTT: Palliative care team visitation and hospice referral
69. Mrs Z complains MYTT told Mr Z its palliative care team would visit him at home despite him living outside of their catchment area and failed to make a referral to the local hospice.
70. During the complaints process, MYTT told Mrs Z it was unable to address this aspect of her complaint because its palliative care team did not see Mr Z. Therefore, it could not ascertain who may have told Mr Z that the MYTT palliative care team would visit him at home. We understand this would not happen because he and Mrs Z lived outside the catchment area. That said, MYTT apologised that a nurse may have told Mr Z that MYTT’s palliative care team would visit them. As explained in the previous sections of this report, a referral was made to the local hospice and they provided support to Mr and Mrs Z over the phone – also visiting Mr Z on 15 August. Mr Z also received support from Locala’s community nurses.
71. We recognise the distress that Mr and Mrs Z would have felt upon being told MYTT’s palliative care team would visit, only for them not to be able to. While we are satisfied that Mr Z was seen (and advice provided via phone) by the appropriate teams once he was discharged, we recognise that this misinformation would have contributed to the confusion and distress Mr and Mrs Z clearly experienced during this difficult time in their lives.
72. Our ‘NHS Complaint Standards’ say organisations should learn from their mistakes and take appropriate action to put things right. This can be a wide range of things from an apology up to a financial remedy and service improvements. In this case, we consider the acknowledgement and apology from MYTT (when coupled with the learning it has taken from the complaint) is enough to put right the impact of these failings. This is because our ‘Severity of Injustice Scale’ says we consider an apology to be enough where the effect on the individual is of short duration and where there are no other adverse effects or ongoing wider impacts. We consider this to be the case here.
MYTT: End-of-life register and intervention plan creation
73. Mrs Z complaints MYTT added Mr Z to an end-of-life plan register, and completed a long-term intervention plan for him, but did not inform Mr Z or his family about this or involve them in its creation.
74. After looking at the clinical records, the complaint correspondence, and seeking advice from our physician and GP adviser (the latter of which we go on to discuss later in relation to Mrs Z’s concerns about the Practice), we cannot see that MYTT added Mr Z to an end-of-life plan register or created a long-term intervention plan for him. It appears from the evidence available to us that the local hospice who provided advice and support to Mr Z in the last few weeks of his life were responsible for leading on this plan, with support from other services.
75. As such, we have not found a failing here.
CHFT: Investigations and bloods tests
76. Mrs Z complains CHFT inappropriately delayed its investigations and blood tests on the ward between 7 August and 11 August. In considering this issue, we have reviewed NICE’s ‘Acute upper gastrointestinal bleeding in over 16s: management’. This says patients with upper GI bleeding should be receive fluids, a blood transfusion for blood loss, and an endoscopy within 24 hours.
77. Mr Z attended A&E on 7 August with upper GP bleeding, coffee ground vomit (vomit that resembles coffee grounds indicating the presence of coagulated blood), and black stools (indicating the presence of blood in the stool). He was assessed, had his bloods taken, and was given intravenous (IV) fluids and an antibiotic called tazocin. This was given because Mr Z was showing signs of possible sepsis. Tazocin is a broad-spectrum antibiotic that is used to treat sepsis.
78. The following day Mr Z was assessed again, and it was decided that he would undergo a gastroscopy later that day. This is a procedure used to examine inside the food pipe, stomach, and upper part of the small intestine. Mr Z also received a blood transfusion this day.
79. On 9 August, the consultant told Mr Z the gastroscopy had identified ulcers. He was given proton-pump inhibitors (PPIs) which decrease acid in the stomach to combat the ulcers. He was also given antibiotics to fight a bacteria that can cause ulcers.
80. Later that day, the plan had been to discharge Mr Z but later in the day his blood count was found to be too low at 71 (with the normal range being between 135 and 170). This meant Mr Z could not be discharged, until it was increased via treatment. Staff also told Mr Z the full blood count that had been taken had been lost, so this needed to be repeated. CHFT apologised for this. Mr Z was discharged two days later, on 11 August, when his condition had stabilised.
81. Our physician adviser told us Mr Z was admitted with signs and symptoms of GI bleeding and he was managed in line with NICE’s ‘Acute upper gastrointestinal bleeding in over 16s: management’. They said Mr Z received the appropriate fluid replacement, blood tests, blood transfusion, and a gastroscopy. They said there was a delay caused by losing the full blood count, as the Trust recognised in its complaint response and apologised for but otherwise the management and communication with Mr Z and his family appeared good.
82. They said staff had realised Mr Z had received little specialist support for his diagnosis of metastatic melanoma (Mr Z was still awaiting the outcome from an MDT at a different trust) and staff at CHFT involved a skin cancer specialist to provide support to him.
83. We recognise there was one instance in this admission where CHFT had to repeat some blood tests because it had lost the full blood count it had carried out. There is no evidence this had a clinical impact on Mr Z. CHFT apologised during the complaints process for this.
84. We know this would have been frustrating for Mr and Mrs Z when they found out CHFT had lost a full blood count and had to repeat this, meaning there was a delay in getting those results. However, as outlined above, CHFT apologised for this, and we have not seen evidence of a wider impact. We consider this to be enough to put things right. This is because our ‘Severity of Injustice Scale’ says we consider an apology to be enough where the effect on the individual is of short duration and where there are no other adverse effects or ongoing wider impacts, which we consider to be the case here.
CHFT: DNACPR discussions
85. Mrs Z complains CHFT inappropriately discussed the implementation of a DNACPR with Mr Z between 8 August and 11 August. She says this was upsetting for her and Mr Z. We think the applicable standards to consider here are the GMC’s ‘Treatment and care towards the end of life: good practice in decision making’, and the joint guidance created by the BMA, RCN, and the Resuscitation Council, ‘Decisions relating to cardiopulmonary resuscitation’ (the Joint Statement).
86. Mr Z received his diagnosis of metastatic melanoma from MYTT and, it is clear from the clinical records we have seen that staff at CHFT only had limited available to them upon Mr Z’s admission regarding his diagnosis. Our physician adviser told us this suggests there is no automatic sharing of medical records between MYTT and CHFT.
87. We can see from the records that when Mr Z was admitted staff were able to establish by speaking with Mr Z that he had recently been diagnosed with metastatic melanoma, was awaiting an MDT meeting to establish if any treatment could be offered, and that he and Mrs Z were lacked in information and support since the diagnosis. We can see that a consultant physician discussed resuscitation with Mr and Mrs Z on 8 August. They entered a note in Mr Z’s records that says, ‘Asked re resus – they have been thinking about this and would like to discuss this when this event settles’.
88. On 10 August, staff approached Mr Z again to discuss resuscitation. On this occasion, Mr Z felt it was too early to discuss, and the doctor provided him with printed information about CPR and DNACPR. The following day, staff tried to discuss Mr Z’s resuscitation status with him but Mr Z said he wanted to wait and did not want to discuss it. He was discharged the following day with plans for oncology and palliative care follow-up where discussions about DNACPR would be expected to be revisited.
89. The GMC’s ‘Treatment and care towards the end of life: good practice in decision making’ says that in situations where cardiac or respiratory arrest is an expected part of the dying process, and CPR will not be successful in restarting breathing and circulation, doctors should discuss this with patients. They should make and record the decision in advance not to attempt CPR because this can help ensure the patient dies in a dignified and peaceful manner. It also says that if the person with lead responsibility for a patient’s treatment and care judges that CPR should not be attempted, because it would not be successful, it must be sensitively discussed with them unless it would cause them serious harm.
90. The Joint Statement also says that where people are known to have an advanced chronic illness, discussion and explanation about the realities of attempting CPR should be considered and, where appropriate, offered in advance of the last few weeks or days of life. CPR cannot reverse a person’s underlying condition, and it may prolong or increase their suffering. While conversations about DNACPR decisions are difficult for clinicians and patients (including those close to the patient), they must not be avoided just because they are difficult or because they may cause some unavoidable distress.
91. It also says that while printed information should not be used in place of a clear and full verbal discussion, printed information should be used as well to raise people’s awareness of the important of decisions about CPR.
92. Our physician adviser told us it was appropriate for staff to ask about Mr Z’s resuscitation wishes. They also told us that while the decision to apply a DNACPR to a person is a clinical decision, it was appropriate to allow Mr and Mrs Z additional time to discuss the decision after staff first raised the subject on 8 August. They told us this was particularly the case when Mr Z’s death was not considered imminent. That is, in the next hours or days. That said, given the cancer Mr Z had, he was at risk of deterioration at any time.
93. Our physician adviser told us the risk and immediacy of the response required in the event of a cardiorespiratory arrest means clear documentation in the clinical records as to whether CPR is appropriate or not. The best way to ensure this is by discussing and considering a person’s resuscitation status early. As such, they told us that the further attempts to discuss this with Mr Z on 10 and 11 August were also appropriate, even though they would be understandably distressing for him and Mrs Z.
94. With this in mind, we do not consider there to be failings with regard to this aspect of the complaint.
CHFT: Provision of information and items for end-of-life care
95. Mrs Z complains CHFT failed to provide her with information and items, such as barrier creams, slide sheets, and medication, to help her provide end of life care to Mr Z when he was discharged on 11 August.
96. We can see from the records available that while Mr Z was in hospital there were no concerns regarding any skin damage and he was assessed as being continent and mobile, albeit his mobility had reduced. As such, our nurse adviser told us there is no evidence that would suggest CHFT was required to provide any items or information to assist Mrs Z in providing end of life care.
97. CHFT told Mrs Z in its response to her complaint that there was no reason for it to provide her with slide sheets, pads, barrier creams or oral care packs. It said anticipatory medicine had already been prescribed by Mr Z’s GP and it understood that when his condition deteriorated after he had been discharged, this was the responsibility of the community teams providing him care. In this instance, we can see this care was provided by Locala, and we give our view on this later in our report.
98. With this in mind, we do not consider there to be failings with regard to this aspect of the complaint.
CHFT: Falls assessment
99. Mrs Z complains CHFT failed to inform her and Mr Z he had been assessed as being at a high risk of falls, and therefore required the assistance of two people for all transfers. She says this meant she often struggled by herself moving Mr Z when he was discharged, and extra support would have been helpful. She told us she took Mr Z home when he was discharged and it was difficult for her to do this.
100. We understand Mr Z’s mobility fluctuated while in hospital. On 7 August, it is documented that he was usually mobile and independent. However, on 8 August, it was noted that Mr Z struggled with a flight of stairs, and that he needed the support of ‘one to two’ people. It is also documented that Mrs Z told staff Mr Z was weak. On 11 August, which is the day he was discharged, it is noted that Mr Z was able to mobilise himself independently.
101. CHFT told Mrs Z that the clinical records indicated Mr Z was still mobile while in hospital, but that is was reduced. It said its review of his clinical records shows mobility was not an issue but that given the fluctuating nature of his mobility a referral to the inpatient therapy team should have been made before his discharge.
102. CHFT said it was disappointed this referral was not made because it would have provided an opportunity to determine if additional support could be given at home. It said this could have lessened the difficulty Mrs Z experienced. It also said that this could have resulted in assistance being provided for Mr Z’s transport to home from hospital on 11 August. Again, it said this could have reduced the difficulty Mrs Z experienced.
103. CHFT apologised and said learning had been shared with the ward matron and ward staff to promote learning and to stress the importance of making appropriate referrals when mobility is reduced. It also said it would make sure all staff were up to date with training around this.
104. We recognise this was upsetting and difficult for Mrs Z. We consider CHFT’s failure to make the appropriate referral meant there was a possibility that Mrs Z would not have needed to struggle as much as she did with transporting Mr Z home from hospital.
105. As mentioned above, CHFT recognised this and has apologised. We consider this to be enough to put things right. This is because our ‘Severity of Injustice Scale’ says we consider an apology to be enough where the effect on the individual is of short duration and where there are no other adverse effects or ongoing wider impacts, which we consider to be the case here.
CHFT: Discharge information
106. Mrs Z complains CHFT failed to provide any discharge information to Mr Z or his GP after his discharge on 11 August. She says this meant they were unclear on next steps which was upsetting.
107. NHSE’s ‘Guidance on the NHS Standard Contract requirements on discharge summaries and clinic letters and on interoperability of clinical IT systems’ says hospital discharge letters should be sent to a GP within 24 hours. DHSC’s ‘Hospital Discharge and Community Support Guidance’ says hospital discharge teams should arrange dedicated staff to support and facilitate hospital discharge. This should include ensuring people have full information about the next steps of their care. They should also be provided with a discharge summary which includes any changes to pre-admission medication.
108. From the clinical records we can see a discharge letter was prepared. This contained the information such as Mr Z’s presenting symptoms, the investigations he underwent, and any next steps for his GP or other services. This was sent to Mr Z’s GP on electronically on the same day. The clinical records also indicate this was given to Mr Z when he was discharged. Our physician adviser told us this is what you would expect to see, and we can see this is in line with the guidance above.
109. We therefore do not consider there to be a failing regarding this issue.
Locala: Hospital bed authorisation
110. Mrs Z complains Locala failed to authorise a hospital bed for use at home and deliver it promptly. She says this meant there was a delay in the hospital bed arriving, which was needed to make Mr Z more comfortable.
111. The NMC’s ‘The Code’ says nurses should take account of the safety of people in their care, taking all reasonable steps to protect people who are at risk from harm. NICE’s ‘Pressure ulcers: prevention and management’ also says devices for the prevention of pressure ulcers should be offered to adult who are assessed as being at high risk of developing a pressure ulcer in community settings (such as at home).
112. In line with this, the community nurses providing care to Mr Z offered him a hospital-type bed with a pressure relieving mattress to protect the integrity of his skin. We can see from the clinical records this was discussed on 7 August and ordered on the same day from a third party medical equipment supplier.
113. We also know that Mr Z was admitted to hospital on the same day (and was later discharged on 11 August). As the bed and mattress were ordered on 7 August, they should have arrived on 8 August. However, this did not happen and we can see the community nurses contacted the third-party medical equipment supplier to chase delivery. The bed and mattress arrived on 12 August which was four days later than it should have been and one day after Mr Z had been discharged.
114. Our community nursing adviser told us the community nurses acted as you would expect them to. They told us that while it is clear the bed and mattress arrived later than expected, this was not because of any delay or error by Locala. We recognise Mr Z would have been without the bed and mattress for one day longer than he may otherwise have (when taking into account his hospital admission from 7 August to 11 August) but, as we have explained, this delay was not because of Locala.
115. With this in mind, we do not consider there to be a failing with regard to this issue.
Locala: Hospital bed size
116. Mrs Z complains the bed Locala ordered was too small and did not have cot sides. She says this left Mr Z uncomfortable.
117. We can see from the clinical records that community nurses ordered a standard hospital-type bed on 7 August, and this arrived on 12 August. Our community nursing adviser told us the standard size mattresses for these beds are usually around 200cm long (80 inches) and 90cm wide (36 inches). We understand Mr Z was six foot one inches tall (73 inches). This means Mr Z fit lengthwise on an 80-inch-long mattress when it was completely flat. However, our community nursing adviser told us that when the bed and mattress are raised at the head-end, so a patient can be sat more upright, this shortens the length of the mattress.
118. We understand extensions for beds can be ordered and, in this case, staff did not order this or check to see whether the bed was comfortable for Mr Z. We understand there are no guidelines relating to the size of beds being ordered (or their extensions) but accept that patients being on beds without extensions will at times mean their feet and legs could come into contact with the bed frame. This can cause discomfort and will increase the risk of skin-related damage.
119. During the complaints process, Locala said its staff did not realise that the size of the bed could have been uncomfortable for Mr Z when he was in a sitting position, and it was sorry that staff had not checked this sooner to ensure it was suitable. Locala said extensions can be ordered and fitted to beds (rather than there being different sizes of beds available to order). However, it also said an extension was not ordered when the nurse who visited Mr Z on 13 August requested one because of his condition. It said that the fitting of the bed extension would require Mr Z being out of bed while it was fitted and due to his rapid deterioration it was felt he was too poorly to be hoisted in and out of the bed. That said, Locala also said that its end of life co-ordinator was of the view that patients may not need to get out of bed for an extension to be fitted.
120. Locala said that its investigation into Mrs Z’s complaint highlighted confusion and a different understanding between staff about bed extensions. As such, it said it would improve staff awareness and education surrounding this. We recognise it was likely Mr Z was uncomfortable for a short period of time when he was in his bed in a sitting position, and this would have been upsetting for Mrs Z. Particularly when she was also witnessing Mr Z’s condition deteriorate.
121. We think Locala’s acknowledgement, apology, and commitment to improving staff awareness is enough to put things right for Mrs Z. This is because our ‘Severity of Injustice Scale’ says we consider an apology to be enough where the effect on the individual is of short duration and where there are no other adverse effects or ongoing wider impacts, which we consider to be the case here.
122. With regard to the absence of cot sides being ordered, our community nurse adviser told us that when the bed was ordered on 7 August, there were no concerns Mr Z would fall out of bed. This is because he was able to reposition himself in bed. We can also see that Mrs Z requested a Zimmer frame around this time, which tells us that he retained at least some mobility.
123. Our community nurse adviser told us using cot sides when they are not needed to stop a person falling out of bed, there is a risk a patient can become trapped in the rails. Similarly, if the patient is confused, they may climb over the rails and cause themselves injury from falling from a greater height. The MHRA’s ‘Safe use of bed rails’ warns about the risk of injury and death from cot sides when they are not needed. As such, they should only be used when necessary. When Mr Z’s condition deteriorated shortly after, staff thought he was at risk of falling out of bed. Cot sides (and a padded bumper to cover the sides) were ordered on 14 August. Our community nurse adviser told us this is what you would expect to happen once Mr Z’s condition deteriorated.
124. With this in mind, we do not consider there to be a failing here.
Locala: Provision of information and items for end-of-life care
125. Mrs Z complains Locala failed to provide adequate information, and the items required to assist her provide end of life care to Mr Z.
126. In considering this aspect of the complaint we have referred to NICE’s ‘End of life care for adults: service delivery’ and ‘Care of dying adults in the last days of life’. These provide guidance on how to provide care to dying adults. They say end of life care should meet the patient’s individual needs, focus on comfort and the reduction of unnecessary medications and interventions. This care should be provided in the patient’s ‘preferred place’ where possible.
127. We also referred to the NMC’s ‘Future nurses: standards of proficiency for registered nurses’ and NICE’s ‘Pressure ulcers’ which say evidence-based and best practices approaches should be used for meeting a patient’s needs for care and support at the end of life, and clinicians should identify, assess, and respond appropriate to uncontrolled symptoms and signs of distress. They also say that people at risk of developing pressure ulcers (and their families) should receive advice on the benefits and frequency of repositioning.
128. We received advice from both our community nurse adviser and nurse adviser when considering this aspect of the complaint.
129. We can see from the clinical records that when Mr Z was discharged from hospital on 3 August, and he was to receive end-of-life care at home. On 4 August, there was an unplanned visit to administer haloperidol to Mr Z because he felt nauseous. Community nurses noted that they asked the GP to prescribe anticipatory medication for Mr Z so they could administer this when he needed it. Our nurse adviser told us this was in line with the NMC’s ‘Future nurses: standards of proficiency for registered nurses’.
130. On 7 August, a community nurse discussed downstairs living with Mr Z because he was deteriorating and, at that point, in his own bed upstairs. As we have explained earlier in this report, a bed was ordered for downstairs living, and they also ordered him a commode. At this stage, Mr Z was able to reposition himself and told the community nurses his pressure areas were fine and intact. On the same day, a visit from the hospice nurses was also requested. As Mr Z was able to mobilise himself (albeit short distances) and was repositioning himself, our nurse adviser told us it was reasonable not to request barrier creams and slide sheets because of this.
131. Further, when nurses arrived to see Mr Z in the afternoon on 7 August, Mrs Z had called an ambulance because he was distressed, had rectal bleeding, coffee ground vomit and abdominal pain. The nurse explained to Mr Z and his family what they could do to alleviate his symptoms and Mr Z decided to stay at home at that point and receive medication from the nurse. They also arranged for an out of hours GP to visit him to review the bleeding and abdominal pain. This is in line with the guidance at paragraph 128 because the nurse took action to ensure Mr Z’s symptoms were addressed, and he could remain at home which is what he wanted.
132. On 12 August, a Zimmer frame was requested by Mrs Z. Our nurse adviser told us this means a slide sheet would not be considered because the use of a Zimmer frame indicates Mr Z had some mobility and could therefore reposition himself.
133. Our community nurse adviser and nurse adviser told us that when Mr Z became bedbound in the early hours of 14 August, nurses checked his skin and pressure areas and noted in his clinical records that they were intact, with no redness. The clinical records also show that Mrs Z and her family were shown how to change Mr Z’s position and were advised to do so every two to three hours. This is in line with NICE’s ‘Pressure ulcers’ which explains that social care professionals should advise people about the importance of repositioning. Staff recommended repositioning Mr Z more frequently than the guidance, which advises repositioning at least every six hours for adults at risk, and four hours for adults at high risk.
134. With this in mind, we consider Locala acted in line with guidance and good practice. Action was taken when it was indicated, and information appears to have been provided. As such, we do not consider there to be a failing with regard to this aspect of the complaint.
135. That said, we recognise and are pleased to see that Locala told Mrs Z during the complaints process that when it orders hospital type beds in the future, it will automatically order a slide sheet to go with it. This means that moving forward a person who may go on to require a slide sheet, even if they do not need it initially, will have one available. Our community nurse adviser and nurse adviser both say this is good practice, and will improve service delivery.
The Practice: GI and haematology referral
136. Mrs Z says the Practice delayed sending a referral to the GI and haematology services on 5 July 2022 and she is concerned this had a negative clinical outcome for Mr Z.
137. Mr Z attended the Practice on 5 July and was seen by a GP. They reviewed Mr Z’s blood test results from a test carried out on 1 July. The results showed Mr Z had anaemia. Anaemia is a blood disorder and occurs when a person does not have enough red blood cells (RBC), or when the RBCs do not function properly. He also had thrombocytopenia (when the cells in your blood responsible for clotting are low in number) and a normochromic anaemia-low platelets (a specific type of anaemia where the RBCs have the typical amount of haemoglobin, but there are not enough of them). Our GP adviser told us this is indicative of a blood disorder.
138. The GP also recognised Mr Z had a history of tiredness for six to eight months which was ongoing but stable. Mr Z had not reported weight loss, and it is noted that his pain and joint aches were better. There were no reports of blood loss via stools (which could indicate an issue in the bowels if present) or sputum (mucus coughed up, which if present could indicate blood in the chest).
139. Mr Z also had an abnormal liver function test result and a raised ferritin (ferritin is a protein that stores iron in the body) level. Our GP adviser told us this was indicative that Mr Z possibly had a gastroenterological problem. The GP subsequently made a referral to the haematologists and gastroenterologists via NHSE’s advice and guidance (A&G) services system.
140. NHSE’s ‘Advice and guidance: guide for general practice’ explains that A&G services improves the interface between primary and secondary care. It allows GPs and other primary care referring clinicians to access specialist advice before or instead of a referral. Our GP adviser told is it also acts as a ‘pre-referral’ process for the hospital specialists (based in secondary care) to assess patients and decide on the urgency of referrals. However, this referral was not sent until 11 July.
141. The GMC’s ‘Good Medical Practice’ says doctors must adequately assess a patient’s conditions, taking account of their history (including their symptoms and other things such as social, spiritual and cultural factors), views and values. It says they must provide or arrange suitable advice, investigations, or treatment where necessary. It says they must also refer the patient to another practitioner when it serves the patient’s needs.
142. The Practice told Mrs Z in its letter dated 13 July 2023 that the referral was marked as routine rather than urgent based on the blood results. This meant there was then a delay in the referral being sent, and it was not sent until 11 July 2022.
143. Therefore, while we do not consider there was a failing with regard to the GP’s assessment, we do consider it is a failing that it took nearly a week to send its referral which was supposed to be urgent.
144. We recognise it was upsetting for Mrs Z to learn that the GP had not referred Mr Z as soon as they should have. She has told us how she feels the care given to Mr Z made him, and her, feel like he was not worth the due care that should have been afforded to him. As set out above, we can see the Practice apologised that the referral was not made sooner, which we are pleased to see.
145. We have also considered whether there was any clinical impact on Mr Z because of the delayed referral. As outlined above, Mr Z was ok in himself when he attended the Practice. Our GP adviser told us Mr Z attended the A&E of the local hospital on 11 July 2022 with a suspected diagnosis of gallstones, and he was treated with intravenous antibiotics. If the referral had been made on 5 July, or shortly after rather than nearly a week later, it is unlikely he would have been seen before his admission on 11 July. As such, we do not consider there was any clinical impact on Mr Z. This means, we consider the impact arising from this failing is one of upset for Mrs Z.
146. Our ‘NHS Complaint Standards’ say organisations should be open and honest when they make mistakes and should take appropriate action to put things right. Our ‘Severity of Injustice Scale’ says we consider an apology to be enough to put things right in instances where an organisation’s mistakes have caused upset, annoyance, frustration and similar with no ongoing adverse effects.
147. We consider the upset Mrs Z experienced as a result of this delayed referral to be something with no ongoing adverse effects. Therefore, we think the Trust has already done enough to put things right with regard to this issue.
The Practice: DNACPR discussion
148. Mrs Z says the Practice inappropriately tried to discuss a DNACPR with Mr Z on 25 July and 4 August 2022 when he was unaware of the severity of his condition.
149. Shortly before Mr Z’s consultation at the Practice on 25 July, he was in hospital between 11 and 16 July. An entry was made in Mr Z’s clinical records on 15 July during the admission, which was visible to the Practice. This entry said that during Mr Z’s admission he was found to have enlargement of his spleen with multiple nodes in his abdomen, which were highly suspicious of metastatic cancer. That is, cancer that has spread from another source. However, the primary source of the cancer was unknown, and the Trust was waiting for the outcome of a liver biopsy and an MDT meeting by the upper GI surgical team.
150. When Mr Z attended his consultation on 25 July, he reported feeling sickly, a poor appetite, and that he needed painkillers. The GP who assessed Mr Z knew Mr Z had widespread cancer but that the Trust were unaware of the original source, and that it was waiting for the results of his biopsy, and the MDT discussion. The GP formulated a plan, expedited an upcoming haematology appointment, discussed pain relief and prescribed Mr Z nutritional supplements. They also arranged a follow-up appointment for two to three weeks’ time depending on the outcome of the Trust’s ongoing investigations and discussions. There is no evidence the GP discussed a DNACPR with Mr Z at this consultation.
151. On 26 July, the GP was contacted by a surgeon at the Trust and they were told Mr Z’s biopsy results showed malignant melanoma (a type of skin cancer that can spread to other parts of the body), and they asked the GP to inform Mr Z of his diagnosis, and that he was being referred to the melanoma MDT.
152. The GP saw Mr Z on 27 July, and he was told about his diagnosis, and the referral to the melanoma MDT. Amongst other things, the GP did attempt to discuss advanced care planning (this is the term used to describe the conversation between people about their future wishes and priorities for care), his resuscitation status (that is, discussions about whether he would want to be resuscitated or have a DNACPR in place) and end-of-life care with Mr Z. This is because the GP knew that given the nature of Mr Z’s cancer, his prognosis was poor, and his care would likely be palliative. Palliative care is the treatment and care a person receives which focusses on managing their symptoms, without curing their condition, to try and give them a good quality of life.
153. Following this, Mr Z spoke to the GP again on 30 July because he had been formally told he had been diagnosed with malignant melanoma which had spread to his liver and other areas. Mr Z looked unwell and was jaundiced (this is when the skin and/or whites of the eyes turn yellow and can be a sign of something serious) and was sent to A&E for assessment. Mr Z was admitted to hospital and discharged on 3 August. During his admission he was seen by a palliative care nurse about pain relief and care to be provided at home by the district nurses. He was also put on the end-of-life care register on 4 August by a local hospice.
154. Also on 4 August, the GP visited Mr Z at home. The GP discussed advance care planning with Mr Z again. GSF’s ‘Advance Care Planning’ says planning and conversations between people, their families, carers and those looking after them are important for improving care for people nearing end of life. It is about enabling provision of care to enable a person to live and die well in the place and manner of their choosing. It enables people to discuss and record their future health and care wishes. Part of advanced care planning discussions involves discussions about resuscitation status. We can see the GP attempted to discuss this with Mr Z again, but he wanted to wait to hear back from the MDT, and the palliative team, before deciding about a DNACPR.
155. We understand Mr Z was shocked by his diagnosis, and it was a lot for him and his family to take in. Mr Z was clearly uncomfortable discussing this, so the GP stopped the conversations upon Mr Z’s instruction and left it for him to choose to discuss these decisions after he had heard from the MDT, and palliative care teams.
156. Our GP adviser told us it was right for the GP to start these discussions with Mr Z given his diagnosis and deterioration.
157. As well as the GSF guidance outlined above, the GMC’s ‘Good Medical Practice’ says doctors must adequately assess their patients, taking account of their history, views and values, and promptly provide or arrange suitable advice and care.
158. Discussions about a person’s resuscitation status, and their end-of-life care is never easy for anybody involved and we appreciate this was a significant shock for Mr Z and his family. We think the GP acted in line with the GSF and GMC guidance when they tried to start these important discussions and therefore do not think there were any failings with regard to this issue, but we appreciate how difficult this was for Mr and Mrs Z, and their family.
The Practice: Morphine prescription
159. Mrs Z says the Practice made an error in its prescription for morphine on 4 August 2022. She says she collected all of Mr Z’s medication on 5 August but, on 6 August she found there was no morphine. She went to the pharmacy to get the morphine but was told there was an error in the prescription and it could not be dispensed. She says she was told to contact the GP on 8 August but Mr Z was admitted to hospital on late 7 August and because she was stressed and anxious, she felt unable to at that time. He was discharged on 11 August and when the district nurses attended his home on 13 August to fit a syringe driver (a device used to administer medication) they needed to ring 111 to get morphine prescribed.
160. We can see from the clinical records available that there was a prescribing error with the morphine sulphate oral solution on 4 August. Originally, the GP had prescribed 300ml of a 10mg/5ml solution with 5-10ml to be taken every four hours as needed for pain relief. However, this was corrected by the GP to 300ml of a 10mg/5ml solution with 1.25-2.5ml to be taken every four hours as needed for pain relief. We can see from the clinical records that this was corrected before the prescription was issued to the pharmacy. However, we recognise Mrs Z says the paper version of the morphine prescription was incorrect, and this is why the pharmacy would not dispense the morphine.
161. Our GP adviser told us that because the error was spotted and corrected by the GP before the prescription was issued, there was no impact on Mr Z clinically because of the GP’s error. Further, we recognise Mr Z was admitted to hospital on 7 August and received pain relief here. However, we appreciate that there appears to have been some confusion in the pharmacy, with regard to the prescription, which meant there was a delay in getting morphine to Mr Z.
162. During the complaints process, the Practice said it appeared the prescription made was valid and it therefore could not ascertain or comment on why the pharmacy felt it was unable to issue the morphine that had been prescribed. That said, we can see the Practice explained that the morphine prescription had not been sent to the pharmacy electronically and it had been printed and sent instead. The Practice apologised and said it has reminded all clinicians to be mindful when sending printed prescriptions, rather than electronic, and that it has encouraged clinicians send all prescriptions electronically where possible. This is because they are easily trackable.
163. We recognise the dispensing of morphine in this instance was not as smooth as it should have been, and this was distressing for Mr and Mrs Z. We are sorry this was their experience. Based on the evidence we have seen, the prescription made out to the pharmacy by the Practice was correct and therefore do not consider there to be failings here.
The Practice: End of life assessment and end of life care plan
164. Mrs Z complains she had to ask the Practice to carry out a review of Mr Z’s end-of-life assessment on 15 August 2022. She also complains the Practice failed to inform and include her and Mr Z in the creation and planning of his end-of-life care plan, also on the same day.
165. We can see from Mr Z’s clinical records that when he was discharged from hospital on 3 August advance care planning and end-of-life care was started.
166. Patient’s ‘Palliative care’ explains that good primary care is about caring for individuals from ‘cradle to grave’. Providing good palliative care is a demanding part of a GP’s job in serving individuals in the community. When a person receives palliative care, this is carried out by an MDT made up of lots of different services and specialisms. For example, GPs, district nurses, and specialist palliative care teams may have an input in the palliative care provided to a patient. Ultimately, good palliative care should be a ‘team effort’.
167. We can see Mr Z’s palliative care was led by a local hospice, with an MDT providing his care. He was deteriorating quickly and the care he required was evolving day-to-day.
168. Our GP adviser told us the Practice were involved in adjusting medication and issuing anticipatory medication on 5 August, after the end-of-life care was started, and was involved in the creation of the clinical management plan and began the syringe driver on 13 August. We can see other aspects of Mr Z’s end-of-life care was provided by other services such as Locala’s district nurses, a local hospice, and there was some involvement by physiotherapists and occupational therapists when a Zimmer frame was ordered. We can also see that referrals were being made for physiotherapy involvement. However, this did not take place because Mr Z sadly died.
169. All services and clinicians involved in Mr Z’s care had access to Mr Z’s clinical records and all were inputting notes which the other members of the MDT could see. Our GP adviser told us there was no requirement for the Practice to review the end-of-life care because it was a team effort, led by the local hospice. When required, the input of the Practice was sought and given.
170. With this in mind, we do not consider there to be failings with this issue. We can see the GP acted in line with guidance and that there was no requirement for them to review the care being provided. They also did not create or plan the end-of-life care plan.