United Lincolnshire Teaching Hospitals NHS Trust

5. Mrs D complains the Trust prescribed her the wrong dose of the breast cancer treatment drug, abemaciclib between October 2024 and January 2025.

6. Mrs D says the prescription was triple the amount it should have been which resulted in her having debilitating side effects. She says between October and January she had no quality of life due to sickness, bowel problems, dizziness, tiredness and brain fog. She also says she was worried the cancer had spread and had a magnetic resonance imaging (MRI) scan on her brain in December due to her symptoms. She has told us she has lost all faith in the NHS and worries about future care.

7. She wants an apology, service improvements and a financial remedy.

8. Mrs D has a diagnosis of stage four terminal breast cancer which in December 2022, the Trust prescribed her with 150mg of abemaciclib which is a breast cancer treatment drug.

9. The Trust reduced the prescription to 50mg in September 2024 due to the side effects Mrs D was experiencing. In January 2025, when arranging to pick up her prescription Mrs D realised that the Trust had been still giving her the increased amount of 150mg for her prescriptions in error.

13. Mrs D complains the Trust prescribed her the wrong dose of the breast cancer treatment drug between October 2024 and January 2025.

14. RPS, medicines, ethics and practice say there should be structured checking process to avoid risk of error, and a pharmacist should re-read the prescription before the final check and always check the product and label against the original prescription.

15. We have seen evidence in the records, Mrs D started on abemaciclib treatment for her breast cancer in December 2022. In September 2024, the Trust reduced this dose to 50mg from 150mg due to its toxicity and the side effects Mrs D experienced. Following this change, Mrs D reported an improvement of these side effects to her consultant on 26 September.

16. Mrs D continued to receive a prescription of 50mg in October and November from the Trust’s pharmacy. However, in early December the prescription she received was an increased amount of 150mg. This was triple the amount of the previous month’s prescription and the higher dose that had been giving her toxicity side effects. Mrs D did not notice this increased amount until early January 2025 when she told the pharmacist, who ensured the next prescription she received was for the prescribed 50mg. Our pharmacist consultant explained this would suggest a dispensing error in December by the Trust’s pharmacy.

17. Mrs D says she experienced debilitating side effects including sickness, bowel problems, dizziness, tiredness and brain fog which meant she lost out on valuable time with her family at Christmas. She says this time is precious as her diagnosis is terminal. She also says she was worried the cancer had spread and had an MRI scan on her brain in December due to her symptoms. She has told us she has lost all faith in the NHS and worries about future care.

18. We can see from the review letter dated 23 December, Mrs D complained of feeling sick alongside pain in her abdomen during this consultation. The Trust also discussed the dizzy spells she had been having and the recent MRI to rule out any brain metastases (cancer cells spread to the brain from another part of the body). From the records, Mrs D was experiencing the dizzy spells before the change in her prescription.

19. Due to the nature of the complaint, we sought impact advice. Our oncologist adviser explained the increase in medication would most likely have caused the stomach pain, diarrhoea and sickness Mrs D has told us about due to the toxicity of the prescription amount. The BNF confirms the side effects for this medication are in line with those Mrs D experienced.

20. We therefore consider the failing we have identified in the management of Mrs D’s prescription for abemaciclib which increased to a triple amount of 150mg for 29 days, has caused the impact she has told us about in relation her stomach pain, bowel issues and sickness.

21. From what she has told us this was over the Christmas period and how this would have impacted the quality time she could spend with her family. We can see that these symptoms improved during January after the medication reverted to 50mg.

22. We cannot say however that this increase in medication for the period of 29 days caused the dizziness she told us about or was the reason for an MRI scan to rule out the cancer had spread to the brain. We were pleased to see this was not the case but recognise Mrs D would have been worried by changes in her symptoms.

23. In its response on 9 January, the Trust has acknowledged the error in the prescription and apologised. It has also corrected the error. We are however not satisfied that this fully recognises the impact this had on Mrs D who experienced debilitating side effects and worried her illness had progressed. Therefore, we consider there remains an unremedied injustice and we will make recommendations.

1. Mrs D is understandably concerned that United Lincolnshire Teaching Hospitals NHS Trust (the Trust) prescribed her with the wrong her with the wrong dose of the breast cancer treatment drug, abemaciclib between October 2024 and January 2025.

2. We were sorry to hear about what happened and how the side effects Mrs D experienced were debilitating and resulted in her not being able to enjoy time with her family during the festive period. It is clear from what she told us how important this time was to her given her terminal diagnosis.

3. After carefully considering all the evidence we have found that the Trust did not act in line with guidance in the management of her prescription for abemaciclib.

4. We consider the identified failing to have led to some of the side effects Mrs D has told us she experienced. The Trust has not acknowledged this impact or how worrying and upsetting this would have been for her. We will therefore partly uphold this complaint and make recommendations at the end of this report.

24. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services.

25. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

26. Our Principles for Remedy reflect the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

What we found

27. Through investigating Mrs D’s complaint, we found:

• A failing in the management of Mrs D’s prescription for abemaciclib which increased to a triple amount of 150mg for 29 days, causing the impact she has told us about in relation to her stomach pain, bowel issues and sickness.

What the Trust should do

28. Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.

29. The Trust should write to Mrs D to:

• acknowledge the failings we found in this report relating to the management of her prescription for abemaciclib. We also recommend the Trust apologise for the impact it has had on Mrs D.

• send a copy of this letter to us by 5 January 2026.

30. Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.

31. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.

32. Following this review, we recommend the Trust:

• pay Mrs D £750 in recognition of the impact the failing has had on her.

• send us evidence it has done this by 25 February 2026.

33. Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure it does not repeat poor service.

34. We recommend the Trust:

• produces an action plan to address the failings found in this report relating to the management of Mrs D’s prescription for abemaciclib • identify the reason for the failing (where possible) • explain the learning taken and set out what it will do differently in the future (or does differently now) • for each action it should state who is/was responsible, timescale for completion, and how it will monitor compliance.

• share the action plan with us, Mrs D, Care Quality Commission and NHS Improvement by 25 February 2026.