The Royal Wolverhampton NHS Trust

7. Miss N complains about the care her mother, Mrs N, received at The Royal Wolverhampton NHS Trust in 2023. She specifically complains the Trust: • failed to tell Mrs N she had gallbladder cancer until she was at an unrelated appointment without family support • failed to provide adequate pain relief between 28 July and 24 August 2023.

8. Miss N tells us the impact of the failure to communicate, was the family had less time to spend with Mrs N before she died, causing them distress. She says it was upsetting for both of them, when her mother found out the diagnosis alone without her family present for support.

9. She says the lack of pain relief led to significant pain for Mrs N which was distressing for her and her family to witness. Miss N says she has lost faith in the Trust.

10. As an outcome, Mrs N is seeking a genuine apology and an action plan for improvement to give reassurance this will not happen to other people.

11. Mrs N (aged 79) had a history of breast cancer. She had surgery, chemotherapy and radiotherapy. She completed her treatment in January 2020, and she remained under regular review by her oncologist with no signs of recurrence.

12. On 15 May 2023, she attended the Trust with abdominal pain. She had scans that suggested she had cholecystitis (inflammation of the gallbladder). The Trust discharged her home on 19 May with a plan to see a surgeon.

13. On 26 May, a surgeon saw her and placed her on the waiting list to have her gallbladder removed.

14. The Trust admitted her on 28 July with abdominal pain. She had a CT scan on 29 July. This suggested gallbladder cancer with spread to the liver and layers of tissue in the abdomen. The Trust discharged her home on 1 August, but did not tell her of her diagnosis.

15. Over the next few weeks, she returned to the Trust due to pain and for an endoscopy (camera test).

16. On 24 August, when attending a routine follow up oncology appointment, her consultant told her about the diagnosis and admitted her for pain relief. Mrs N sadly died a month later.

Communication of the diagnosis

21. Mrs N had a CT scan on 29 July. This suggested gallbladder cancer.

22. Her medical records show on 31 July, a doctor noted Mrs N was unaware of the CT findings. On 1 August the notes show a registrar told another doctor to prepare a discharge letter without the details of the CT findings.

23. On 4 August, Mrs N’s case was discussed at a multi-disciplinary team (MDT) meeting. The plan was for the consultant surgeon to tell her of the diagnosis. This did not happen as she attended the emergency Department (ED) the following day. The medical records of her ED attendance state she was informed of the recent MDT outcome. Miss N says this did not happen.

24. Mrs N was seen by the Trust again on 13 August in ED, and the endoscopy unit on 19 August. There is no documentation of her being told the diagnosis on either of these dates.

25. On 24 August, she attended an appointment with her oncologist. This was a routine follow up appointment for her breast cancer. In this appointment, the doctor realised she had not been told her diagnosis and explained it to her. Her medical records confirm she was unaware of the scan results. The doctor called Miss N and she was shocked to hear the results on the phone.

26. GMC guidance says doctors must share information with patients, and work with them to help make decisions about their care. They must explain their condition, likely progression and treatment options. They must also consider and support those close to patients.

27. GMC guidance also says clinical records should reflect all the information that doctors give to patients.

28. Our surgical adviser explained that breaking bad news should take place in a calm environment, with a relative present and ideally a cancer nurse specialist.

29. Our surgical adviser explained that before the Trust discharged Mrs N on 1 August, staff should have had a conversation with her and warned her of the possibility of cancer and the next steps. This should have been documented. Miss N’s account, the medical records and Trust’s complaint response all suggest this did not happen.

30. On 5 August, the notes indicate Mrs N was told the diagnosis, but this is not supported by later entries indicating she was unaware. Our surgical adviser explained the responsibility for communication lay with the consultant surgeon. As above, the ED would not be a suitable environment to explain the diagnosis, as appropriate support was not available, from Mrs N’s family or a cancer nurse specialist.

31. Based on the above, we find the Trust did not comply with GMC guidance in communication and record keeping.

32. In its complaint response, the Trust apologised for the failure to communicate Mrs N’s diagnosis. It said the consultant was under the impression that other staff had told Mrs N, but this was not the case. We consider it was the consultant’s responsibility to ensure this had taken place, in an appropriate manner. The Trust confirmed there was no evidence Mrs N’s diagnosis was discussed with her at any point.

33. We find the Trust failed to communicate Mrs N’s diagnosis to her.

34. Miss N told us the impact of this, was that Mrs N was told her diagnosis when at an unrelated appointment, with no family support. She told us this was incredibly distressing for her mother and for the rest of the family. The delays in telling her the diagnosis, meant the family had less time to spend with her before she sadly died.

35. We can see that the impact Miss N complains of, would reasonably flow from the failings we have found.

36. The Trust has taken some steps to remedy its acknowledged failings. We reviewed these to determine if enough appropriate action had been taken.

37. In response to the complaint, the Trust created an action plan to discuss with medical staff and ensure information given to patients is documented accurately.

38. Given the serious nature of this failing and the multiple missed opportunities to tell Mrs N her diagnosis in a suitable environment, we find the Trust should make a fuller apology in recognition of this. We also find there are more improvements the Trust can make to prevent failings happening again.

Pain relief

39. Miss N told us the Trust did not adequately manage her mother’s pain from 28 July, to her readmission to hospital on 24 August.

40. On her admission to hospital on 29 July, Mrs N’s pain score was 8/10 at 1.12am. Nurses gave her buscopan (medication to treat stomach cramps) at 2.15am. Her pain was 9/10 at 8.30am and nurses gave her paracetamol. The nursing notes do not mention Mrs N being in pain in any of the remaining records during this inpatient stay, until 1 August.

41. On 1 August, the nursing notes state they gave her pain relief at 1.48am. Her drug chart shows staff gave her oral morphine once on 30 July, and twice on 1 August.

42. The Trust said in its final complaint response, that as her pain was managed prior to her discharge, there was no indication to discharge her with pain relief.

43. Section 16c of GMC guidance says: ‘In providing clinical care you must take all possible steps to alleviate pain and distress whether or not a cure may be possible.’

44. NICE guidance on managing mild to moderate pain says to follow a stepwise ladder when managing pain. This is a framework to provide mild pain relief to start, and then move through different levels of stronger medication.

45. Our surgical adviser explained the Trust knew Mrs N had a diagnosis of metastatic cancer and staff should have anticipated she was likely to experience worse pain as the cancer grew.

46. During her inpatient stay, she had used paracetamol, buscopan and oral morphine for pain relief and none of these were prescribed for her on discharge. She required oral morphine twice on the day she was discharged, so it was clear that she needed some regular pain relief in keeping with the GMC and NICE guidance above.

47. On 5 August, Mrs N attended ED with abdominal pain. The drug chart shows she was prescribed 1-10mg intravenous morphine, titrated to effect. This means the member of staff administering it could give her the amount she needed to relieve her pain.

48. The dose of morphine that Mrs N was actually given has not been recorded. The discharge letter states Mrs N was given oral morphine. This does not match the drug chart stating it was given into her vein. There is no documented discussion about what pain relief Mrs N had at home, or a plan for how she should manage her pain.

49. Our ED adviser explained adequate pain relief is an important part of medicine. As she required intravenous morphine in ED, it is clear that she needed escalation of whatever pain relief she was taking at home. This would follow the NICE stepwise pain relief guidance. As she needed opiates in ED, it is likely she would have needed these at home.

50. She should also have been encouraged to follow up any plan for pain relief with her GP. We find there was a failure to follow the NICE guidance and prescribe regular pain relief.

51. On 13 August, Mrs N attended ED with abdominal pain again. On this occasion, she was sent home with oral morphine. This was in line with NICE guidance.

52. On 19 August, she attended the Endoscopy unit for her flexible sigmoidoscopy. It is noted that she was complaining of pain. She was on co-codamol and buscopan regularly at home. Our surgical adviser explained this was another missed opportunity to review her pain relief. Mrs N was reporting pain despite being on regular pain relief at home.

53. We find the Trust did not meet GMC and NICE guidance on 1 August, 5 August and 19 August to provide better pain relief.

54. Miss N told us the impact of this, was her mother was in significant pain which was distressing for her and the family.

55. As set out in paragraph 45, as Mrs N’s cancer grew, it was likely to cause her more pain. On 24 August, when she saw her oncologist, the medical records state she was in ‘severe pain’ and required admission for pain management.

56. We find the impact on Mrs N was that she experienced unnecessary pain. The impact on Miss N was the distress of seeing her mother experience this pain.

1. We were sorry to hear of the circumstances of Miss N’s complaint. She told us how distressing it was for her mother, Mrs N, to find out her diagnosis alone without family support.

2. We appreciate how difficult this must have been. We can see how upsetting it was to see her mother struggling with pain.

3. We have found the Trust failed to tell Mrs N of her diagnosis, and failed to provide adequate pain relief. These led to emotional distress on Mrs N and her family, as well as physical pain to Mrs N.

4. The Trust has apologised regarding communication and taken some steps to learn from what happened. There are further actions it could take, given the serious nature of the failings and impact.

5. The Trust has not done enough to put right the failings with pain relief. We therefore uphold Miss N’s complaint.

6. We recommend the Trust provides a letter of apology to Miss N. We also recommend it creates an action plan outlining the service improvements it will take regarding communication of a serious diagnosis, and pain management.

57. In considering our recommendations, we have referred to the ‘NHS complaint standards’. The Complaint Standards support organisations to provide a quicker, simpler and more streamlined complaint handling service. They have a strong focus on: • early resolution by empowered and well-trained people • all staff, particularly senior staff, regularly reviewing what learning can be taken from complaints • how all staff, particularly senior staff, should use this learning to improve services.

58. In line with this we recommend the Trust should write to Miss N to acknowledge its failings in full relating to communication of her mother’s diagnosis, and regarding the lack of pain relief it provided to her. It should apologise for the impact on her these failings had. It should send this letter within four weeks of our final report.

59. In relation to service improvements, we recommend the Trust: • should produce an action plan to explain how it intends to ensure the failings we have seen relating to communication and pain relief do not happen again. It should reflect communication taking place in an appropriate setting with relevant support and accurate documentation • identify the reasons for the failing • explain the learning taken and set out what it will do differently in the future (or does do differently now) • state who is responsible for each action, the timescale for completion, and how it will be monitored • share the action plan with us and Miss N within three months of our final report.