Response to pain
18. Mrs U says that on 19 April staff dismissed her brother’s pain as normal following the insertion of his PEG (feeding tube) and failed to investigate its cause. She states the Trust denies Mr O was in any pain on that day even though staff gave him morphine. She adds that the clinical records do not document the reason why staff gave him morphine.
19. She says nurses let her brother down as they were unaware of the Trust’s scope of practice (SOP, a set of detailed step by step instructions) for post-PEG care. She considers this is evidence that his care fell below an acceptable standard.
20. General Medical Council (GMC) guidance on ‘Good medical practice’ says doctors must provide a good standard of practice and care. If they assess, diagnose, or treat patients they must adequately assess the patient's conditions, take account of their history and where necessary examine the patient.
21. This guidance explains doctors must promptly provide or arrange suitable advice, investigations, or treatment where necessary and refer to another practitioner when this serves the patient’s needs.
22. The Trust’s SOP states if there is prolonged or severe pain following the procedure staff should obtain urgent advice from nutrition clinical nurse specialists or the gastroenterology team. They should also consider an urgent CT scan (detailed X-ray), contrast study (a test where dye is introduced into the body to make specific areas show up better on scans) and surgical review.
23. Clinical records show Mr O reported pain during a ward round at 10.45am on 19 April. The Trust’s SOP states urgent action, or investigation is only necessary if pain is severe or prolonged. The records describe Mr O’s pain as mild which our adviser said is common for up to 72 hours after PEG insertion.
24. We have not seen evidence that Mr O’s pain on 19 April was prolonged or severe which means we cannot say an urgent clinical response was necessary.
25. Our adviser said that when mild pain occurs after PEG insertion, clinicians should monitor for red flag symptoms of complications such as fever, swelling or an elevated NEWS (national early warning score). NEWS is a scoring tool doctors use to calculate the severity of a patient’s illness and risk of deterioration. The higher the score, the higher the risk of deterioration.
26. Clinical records show Mr O’s NEWS score was low and he had no red flag symptoms. Our adviser confirmed the only action clinicians needed to take on 19 April was to manage Mr O’s pain. They said this was because there were no signs of complications requiring further investigation.
27. We understand he received morphine and cannot see he reported further pain until the following day. This suggests that his pain was managed.
28. Mrs U says staff did not clearly document why her brother received morphine in his medical records. The Trust has accepted there were areas for improvement in its record keeping. We are satisfied staff gave Mr O morphine to manage his pain.
29. Mr O’s condition changed the following day. At around 10am he became distressed and appeared to be in greater pain.
30. Nurses requested an urgent medical review, and a doctor attended approximately two hours and 15 minutes later. The doctor recorded that Mr O had a firm abdomen with no bowel sounds. Our adviser confirmed these are red flag symptoms of potential post-PEG complications meaning Mr O required urgent investigation and surgical input.
31. The doctor arranged an urgent CT scan and attempted to contact the surgical team while examining Mr O. Our adviser said this was a prompt response in line with good clinical practice.
32. The doctor suspected peritonitis which is an infection and inflammation of the lining of the abdomen. Peritonitis is a known complication of PEG insertion and people with diabetes are at higher risk of developing it. It can present as abdominal pain, an increase in white blood cells, ileus (when the bowel stops moving) and fever.
33. We know Mr O sadly died from peritonitis. We have seen no evidence he showed signs of this complication on 19 April. This means we cannot say staff should have taken steps to identify this sooner.
34. The evidence we have from 19 April suggests Mr O had mild pain for which he required and received pain relief. Our adviser confirmed this was suitable treatment in line with GMC guidance.
35. Mr O began to show signs of post-PEG complications on 20 April. Clinicians recognised this, arranged investigations to confirm the diagnosis and sought urgent surgical input.
36. Our adviser confirmed these were suitable investigations in line with GMC guidance. We have seen no indication of failings in this aspect of the complaint.
Scope of practice
37. Mrs U raised the issue of nurses being unaware of the Trust’s SOP as supporting evidence for her wider concern that her brother did not receive the investigations he needed, when he needed them.
38. The evidence we have seen shows Mr O did receive the investigations he needed when these were necessary. This means that although the nurses’ lack of awareness of the SOP was regrettable, it did not prevent Mr O from receiving the care and treatment he needed.
39. Our Complaints Standards explain where something has gone wrong staff should implement improvements to ensure this does not reoccur. We understand the Trust has carried out training to support its staff’s understanding of the SOP. We consider this to be a sufficient step to take in line with our Complaints Standards.
40. We recognise nurses being unaware of the SOP caused Mr O’s family distress. The Trust has put things right by apologising for the impact to the family and taking steps to improve its service. This is in line with our Complaint Standards, and we do not consider any further action is needed.
Surgical decision making
41. Mrs U complains staff decided her brother was too unwell to undergo surgery to treat complications from the PEG insertion. She says it was not certain her brother would not survive the operation, and he would have wanted staff to try.
42. Royal College of Surgeons guidance says doctors should carry out a comprehensive risk assessment before agreeing to perform emergency surgery on a high-risk patient. It says doctors should not carry out surgery if the risk of death or morbidity (the harm, disability or severe loss of function caused by surviving a major procedure) are very high.
43. The guidance says doctors should make decisions around surgery in the patient’s best interest and prioritise quality of life over prolongation (extending life when it would involve significant suffering or very limited function).
44. Staff identified Mr O needed abdominal surgery on 20 April. A multi-disciplinary team of clinicians including a surgical consultant, intensive care unit consultant, rehabilitation consultant and critical care discussed carrying out surgery. This was in line with RCS guidance which says multi-disciplinary input is essential.
45. The MDT jointly determined Mr O was unlikely to survive surgery and decided not to offer this. Our adviser said for surgery to be clinically appropriate its benefits must outweigh its risks and there must be less than a 50% chance of death from the procedure.
46. Clinicians can use the National Emergency Laparotomy Audit (NELA) score to estimate a person’s risk of death from surgery. A NELA score is a risk assessment tool clinicians use to calculate a patient’s risk of dying within 30 days of abdominal surgery.
47. We have seen Mr O was recovering but not fully recovered from a traumatic brain injury. He had recently had brain surgery and an extended intensive care unit stay where staff identified possible cancer. He also had diabetes and heart failure. Our adviser explained this made him a high-risk patient.
48. Our adviser calculated Mr O’s NELA score as 69.78%. This means there was almost a 70% chance he would die within 30 days of surgery, and the chance of harm, disability or severe loss of function if he survived was even higher.
49. Our adviser said if Mr O did survive, his cognition, communication and mobility would be worse. It is likely he would have been bedbound, doubly incontinent, unable to move and dependent on 24-hour care.
50. Our adviser said clinicians acted in line with RCS guidance in not performing surgery as the risks significantly outweighed any potential benefits. The guidance makes it clear doctors must prioritise quality of life over extending life when it would involve significant suffering or very limited function.
51. We recognise Mrs U considers clinicians should have carried out surgery regardless of the risks. This must have been an incredibly difficult time for her.
52. We know Mr O had a high chance of dying within 30 days of surgery and an even higher chance of a very poor quality of life if he survived. Our adviser said surgery would not have been in his best interests and the decision not to proceed was in line with RCS guidance. For this reason, we have not seen any indication of failing in this aspect of the complaint.
53. We recognise how deeply difficult this was for Mr O’s family. Staff had previously told them he may not survive his brain injury, and he recovered better than expected. We understand they hoped he may overcome the risks of surgery in the same way. The evidence shows his risk of death from surgery was high and survival would likely have meant a very poor quality of life.
54. We recognise the emotional impact of the decision not to perform surgery, particularly as Mr O sadly died later that day. We understand why his family continue to feel surgery should have gone ahead. We hope this part of our decision offers some reassurance.
Stopping treatment
55. Mrs U complains about staff’s decision to stop treating her brother with metaraminol. She considers they should have continued providing this until his son and daughter arrived.
56. Our adviser said there are three guidelines that are relevant for this aspect of the complaint: • FICM guidance on care at the end of life • GMC on treatment and care towards the end of life • NICE guidelines on end-of-life care for adults
57. Each makes it clear that when a person may be entering the last days of life, doctors should stop any prescribed medicines that are not providing symptomatic benefit (improving a patient’s symptoms) or that may cause harm.
58. Metaraminol is a vasopressor meaning it is used to maintain blood pressure. Clinical records show staff began giving Mr O this medication in the resuscitation department after he became acutely unwell during a scan. Our adviser said this medication stopped Mr O’s blood pressure from dropping and gave clinicians time to decide whether surgery was clinically appropriate.
59. Staff decided not to prescribe further metaraminol once the multidisciplinary team moved Mr O to palliative care. Our adviser confirmed this decision was in line with the above guidelines. They explained metaraminol would not have provided any symptomatic benefit as it would not treat or cure Mr O.
60. Our adviser said clinicians could have stopped giving Mr O metaraminol in the resuscitation department. Instead, they made the decision to continue providing this until the dose ran out. This meant they were able to move Mr O to a private room where he died amongst his family.
61. We understand how devastating the decision not to administer further medication was for Mr O’s family. Metaraminol had temporarily supported his blood pressure, and his family considers continuing this might have given him enough time for his children to arrive and say goodbye. We recognise he sadly died before they could be with him.
62. The guidance is clear that treatment decisions at the end of life must be based on what is right for the patient, not on the wishes or needs of relatives. Our adviser said further metaraminol would only have prolonged Mr O’s dying without providing comfort or benefit. For this reason, we cannot say staff should have continued the medication and we have not seen anything went wrong in this part of the complaint.
63. We fully recognise the distress the family continue to feel.
Complaints handling
64. Mrs U complains the Trust delayed responding to her complaint and did not keep her updated. She says its communication during the process was poor. She explains the Trust repeatedly missed its own deadlines for providing a response, meaning she had to chase for updates.
65. We can see Mrs U complained to the Trust on 29 May 2023 and received an acknowledgement the following day. The Trust asked for consent from Mr O’s next of kin (his wife) and confirmed it had this on 7 June. On 21 June it wrote to Mrs U to set out what it would investigate and gave a target response date of 20 August.
66. Mrs U wrote to the Trust asking for an update on 20 August. It replied with a revised deadline of 18 September. After the Trust missed this, Mrs U contacted it again.
67. The Trust responded on 20 September and explained its response was awaiting executive sign off and should be with her by 29 September. It acknowledged the delay and said it would let her know in advance if there were any other delays. It did not meet this deadline and issued its first response on 15 November. It is unclear whether it provided any further updates between September and November 2023.
68. Mrs U returned to the Trust with outstanding concerns on 16 November, which the Trust acknowledged the same day. On 27 November it confirmed seven areas for further investigation and set a target response date of 22 January 2024. It said it would keep Mrs U updated.
69. The Trust missed this deadline and Mrs U contacted it for an update on 2 February. The Trust apologised and set a new deadline of 29 February. When the Trust also missed this deadline Mrs U approached us for support.
70. Following our contact the Trust apologised to Mrs U on 6 March and set a new deadline of 29 March. It did not meet this.
71. Mrs U contacted us again in April. After we requested an update, the Trust advised it could not confirm when its response would be ready and gave a further deadline of 20 May. It missed this and set a new deadline of 10 June after further contact from Mrs U. The Trust did not meet this.
72. On 10 June, the Trust told us it was unable to meet its previous commitment and gave a revised deadline of 2 August. The Trust did not meet this deadline and on 9 August we asked for an update. It said it could not provide a response before the coroner’s inquest on 16 August.
73. On 15 August, the Trust contacted Mrs U to apologise and explained the response was undergoing sign off. On 27 August, the Trust wrote to her to explain part of its response was ready. It offered to send a partial response, but Mrs U preferred to wait for the full version.
74. On 1 October, the Trust wrote to Mrs U again to say the full response was awaiting final sign off and she should receive this by 22 October. It issued the response on 18 October.
75. The relevant guidance here is the NHS complaints regulations. These do not set a specific timeframe for issuing a written response. Instead, they require organisations to provide a response as soon as reasonably practicable. This is because investigations will vary in complexity and duration.
76. Our complaint standards also say organisations should keep complainants regularly informed about progress and the reasons for any delays.
77. The Trust took just under six months to issue its first response. We can see it did respond to Mrs U’s requests for updates during this time. We recognise Mrs U would have preferred it to have proactively updated her.
78. NHS complaints regulations only require an organisation to write to a complainant if it cannot respond within six months. Organisations should explain the reasons for the delay and when the complainant can expect a response.
79. The Trust provided its first response within the target timescale set out in NHS complaints regulations. This meant it was not required to provide specific updates. We have seen no indication of failings in the Trust’s complaints handling between May and November 2023.
80. Mrs U raised outstanding concerns on 16 November 2023. The evidence suggests the Trust had drafted its second response and this was almost ready by May 2024. Around this time, it received new queries from the coroner that Mrs U and her family wanted it to address. We consider this meant the Trust could not send its response as planned without it being incomplete.
81. It is clear the Trust was aware it would not be able to provide its second response within six months of receiving Mrs U’s outstanding concerns. We consider it should have written to her in May 2024 to explain the delay. It did not do this. It also did not provide regular updates after this, meaning Mrs U had to repeatedly chase for information until she received the response in October 2024.
82. Overall, we have seen an indication that something went wrong with the Trust’s complaint handling between May and October 2024. Its actions during this time were not in line with NHS complaints regulations or our complaint standards.
83. We recognise Mrs U was already mourning the loss of her brother at the time so the Trust’s lack of contact will have added unnecessary upset and frustration at an already difficult time.
84. Mrs U experienced additional upset and frustration as a result of these delays for around five months until she received the Trust’s response on 18 October 2025.
85. We understand Mrs U wants the Trust to acknowledge its mistakes, apologise for them, improve its service and pay her brother’s wife a financial remedy.
86. We contacted the Trust and set out Mrs U’s concerns about its complaint handling. It fully acknowledged it had let Mrs U down by not keeping her updated. It has agreed to write to her to acknowledge its mistakes, apologise and explain how it has improved its complaints process since it handled her case.
87. Having carefully considered this in in line with our remedy guidance, we are satisfied these actions are proportionate to put right the injustice Mrs U experienced.
88. For the reasons set out above, we have decided to take no further action in Mrs U’s complaint.
89. We understand the events described in our statement have been very distressing to Mrs U and her family and appreciate their experience continues to affect them. We hope we have been able to provide some reassurance that we have carefully considered Mrs U’s concerns, and we thank her for bringing this complaint to our office.