A practice in the City of Portsmouth area

6. Mrs F complains on behalf of her late husband about treatment received by a GP at the Practice from June 2023 to May 2024. Specifically, she complains the GP:

• stated her husband was dying when the GP did not know this • discussed her husband’s medical condition with a third party without consent • forced a morphine tablet down her husband’s throat without consent by squeezing his cheeks • gave end of life injections which hastened her husband’s death • continued administering morphine against his will.

7. Mrs F says the end of life injection and continued administration of morphine were against their religion as they believe death should be natural and not brought forward by medications. She says her husband’s condition deteriorated rapidly after these were administered, and he had to be admitted to hospital where he sadly died. Mrs F feels the GP’s actions hastened her husband’s death.

8. Mrs F says these events have caused her significant distress and have added to her grief at an already difficult time. She says the GP’s unprofessional actions in saying her husband was dying and discussing his medical condition with a third party added to their distress and concerns about the care her husband received.

9. As a result of bringing the complaint to us, Mrs F is seeking service improvements and a financial remedy.

10. Mr F had a known history of liver cancer. Mr F’s symptoms worsened in 2023, and he was experiencing significant back pain which was affecting his ability to mobilise. Mr F was referred for investigations into this and was diagnosed with metastatic bone cancer (cancer that has spread from its original location).

11. There was some initial confusion as to the prognosis and treatment for Mr F’s further cancer, and his family strongly wished for him to start curative treatment for this.

12. Mr F attended an oncology appointment in January 2024, where it was explained further chemotherapy and cancer treatment would not be recommended, and that Mr F had a very poor prognosis. The oncologist advised that Mr F’s ongoing care would be palliative, to help manage his pain and ensure his comfort.

13. Mrs F made the Practice aware that they did not wish to make Mr F aware of his prognosis and extent of his illness. The family wished instead to work towards building Mr F’s health up so he might be eligible for further treatment. The Practice made Mrs F aware that it would not start any conversations about this, but it would need to provide honest answers to any questions Mr F may directly ask them.

14. Mr F was cared for at home and a package of care was in place to support Mr F with personal care, getting dressed and undressed, and welfare and safety checks.

15. In April 2024, a discussion was held with Mr F around resuscitation and Mr F agreed it would not be in his interests to be resuscitated. Mrs F was noted to be concerned about this decision as she felt this was against their religious beliefs. Mrs F also raised concerns about the prescribing of ‘anticipatory’ medications (medicines which may be needed to manage symptoms likely to occur in the patient’s last days of life), as she felt these were put in place to hasten her husband’s death.

16. In May 2024, Mr F was admitted to hospital as he was experiencing shortness of breath. He remained in hospital until his death a few weeks later.

20. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

Comments about Mr F being at the end of his life

21. Mrs F complains a GP at the Practice said Mr F was at the end of his life. Mrs F says the GP would not have known this, and it was inappropriate to make this comment.

22. We note the family did not wish to make Mr F aware of his prognosis and extent of his illness and wished to focus on a possible positive outcome. This is understandable and we appreciate the family wished to minimise any distress to Mr F and ensure his comfort.

23. We have not seen specific reference to this comment in the records but can see it was likely that a comment of this nature was made at some point in Mr F’s care. We have therefore considered if it was appropriate to say Mr F was at the end of his life, and if it was appropriate to discuss this with Mr and Mrs F.

24. Mr F’s diagnosis of metastatic bone cancer was made by the oncology team at the hospital. We can see there was some initial confusion around Mr F’s treatment and prognosis, and the oncologist met with Mr and Mrs F on 22 January 2024 to discuss this further. The oncologist explained further chemotherapy and cancer treatment would not be recommended, and that Mr F had a very poor prognosis.

25. The GMC guidance ‘Treatment and care towards the end of life’ says patients are considered to be ‘approaching the end of life’ when they are ‘likely to die within the next 12 months’. This includes patients whose death is imminent (expected within a few hours or days) and those with:

• advanced, progressive, incurable conditions • general frailty and co-existing conditions that mean they are expected to die within 12 months • existing conditions if they are at risk of dying from a sudden acute crisis in their condition • life-threatening acute conditions caused by sudden catastrophic events.’

26. We can see Mr F met this definition as he had an advanced and incurable condition, as his liver cancer had spread to his bones and further treatment of this was not recommended. We recognise the GP would not have been able to say with certainty when Mr F may die, but we consider it was appropriate to consider he was approaching the end of his life, based on his health and the information provided by Mr F’s oncologist.

27. We have next considered if it was appropriate for the GP to have told Mr and Mrs F that Mr F was approaching the end of his life. In considering this, we appreciate the very difficult position Mrs F was in, as she was caring for her husband and wished to protect him from distress.

28. The GMC guidance ‘Treatment and care towards the end of life’ says clinicians should discuss care with patients who have capacity to be involved in decisions about their care. Mr F was noted to have capacity to be involved in these discussions. We consider it was appropriate for the GP to explain Mr F’s health and prognosis, as this information would be needed for Mr F to appropriately consider his options for care. We can see Mr F would have needed this information to be able to state his preferences around resuscitation, medication and where he wished to be cared for.

29. Overall, we do not see indications of failings in the Practice’s care and communication in relation to this concern, and we consider its actions were in line with the GMC guidance.

Concerns about talking to a third party without consent

30. Mrs F complains that a GP at the Practice discussed Mr F’s condition with a third party without any consent.

31. We can see from the records that both Mr and Mrs F were involved in a conversation with the Practice on 9 May 2024. The conversation was around anticipatory medication (medications prescribed in advance to help with common symptoms at the end of life) which Mrs F disputed. Mr F confirmed which medication he had available, and the conversation was abruptly ended by him.

32. When the GP called back, the call was answered by a third party who acted as a conduit by taking the information from the GP and relaying it to Mr and Mrs F.

33. The GMC guidance ‘Good practice in handling patient information’ says that consent may be explicit or implied. Implied consent refers to circumstances in which it would be reasonable to infer that the patient agrees to the use of the information, even though this has not been directly expressed.

34. The call from the GP took place on Mr and Mrs F’s landline which was answered by a third party who acted as a calm go-between, relaying information from the GP to Mr and Mrs F. We can see from the records the conversation continued smoothly. In line with this, we consider the GP appropriately considered they had implied consent from Mr and Mrs F.

35. Overall, we do not see indications of failings in the Practice’s communication in relation to this concern, and we consider its actions were in line with the GMC guidance.

Concerns about medication being given without consent

36. Mrs F complains that Mr F was forcibly given morphine against his will and had his mouth forced open so a tablet could be given to him.

37. We have carefully considered both accounts of these events. The initial complaint made by Mrs F’s son on 14 May 2024 says his father had protested on numerous occasions that he did not wish to take morphine, unless the pain was excessive. He said this request was often ignored and his father was told to ‘open his mouth so that the morphine pill could be “popped in”’. Mrs F’s son says it was only the intervention of the family that stopped this from happening.

38. The Practice responded to these concerns in its complaint response of July 2024. This noted that Mr F had capacity to make decisions about his care, and these decisions had been respected by the Practice. The Practice goes on to say that forcing a patient to open their mouths to take medication they did not want would go against all professional and humane conduct.

39. In addition to the Practice’s response, this concern was also considered by the ICB. The ICB’s complaint response explained the Practice had spoken to all staff about this allegation and none recalled administering any oral medicines to Mr F and there was also no documentation of any incident regarding this. The ICB explained it could not come to a firm conclusion about what happened due to the differing views of the events.

40. We therefore have conflicting accounts of these events. We have independently considered all the available evidence to see if we can reach a view about what happened.

41. The GMC guidance ‘Decision making and consent’ says doctors must respect a patient’s wish to decide, even if the doctor considers the decision to be unwise. It also says records should be kept up to date with the information provided and the decision reached.

42. In line with this, we can see a number of records relating to Mr F’s wishes around his medication and treatment and can see Mr F’s wishes were respected, even when it was explained that some of the decisions were against medical advice. The records on 15 April 2024 also show Mr F had made the GP aware that he had stopped taking the morphine himself as he was concerned about the side effects of this.

43. We are very unlikely to be able to reach a view that Mr F was given medication against his will. This is because we were not present and there is no further evidence around these events. As above, we can also see careful consideration was given to Mr F’s wishes in other areas of his care.

44. In addition, the initial complaint suggests the clinician told Mr F to open his mouth for the medication, but the family intervened to stop this. This therefore suggests Mr F’s mouth was not forcibly opened for the medication.

45. We can see that the Practice took these concerns seriously, in line with our ‘Complaint standards’. These say organisations should give a fair and balanced account of what happened and the conclusions they have reached and respond with empathy. In line with this, we can see the Practice spoke to staff and reviewed the records and provided a careful response explaining its findings and recognising the impact of these events.

46. Overall, we do not see indications to suggest further action is needed in relation to this concern. We recognise how difficult these events will have been for Mrs F and her family and recognise their work to advocate for Mr F’s wishes. We hope our explanation provides some reassurance to Mrs F and her family

Concerns about medication being given to hasten Mr F’s death

47. Mrs F complains that Mr F was given an end of life injection with the intention of hastening his death.

48. The GMC guidance ‘Treatment and care towards the end of life’ states it is not allowed for clinicians to prescribe medication for the intention of shortening someone’s life. The act of intentionally bringing forward a patient’s death would be considered very seriously.

49. We have carefully considered the medications Mr F was prescribed. We can see Mr F was prescribed ‘anticipatory medications.’ These are medications prescribed in advance, to help with common symptoms at the end of life, such as anxiety, pain, nausea and vomiting, so these are available for when they are needed.

50. We can see Mr F was prescribed oxycodone (for pain, breathlessness and cough), haloperidol (for nausea, vomiting and delirium), hyoscine butyl bromide (for distressing oral/chest secretions), and midazolam (for anxiety, agitation and breathlessness). Our adviser explains these medications were prescribed at appropriate doses with the intention of reducing his symptoms and pain as much as possible when needed.

51. Overall, we have not seen indications to suggest these medications would have hastened Mr F’s death and consider these were prescribed appropriately in line with the above GMC guidance.

Conclusion

52. Overall, we have not seen indications to suggest failings in the Practice’s care of Mr F and we can see the decisions made were in line with the relevant guidance. We hope this statement clearly explains our reasoning.

53. We recognise how upsetting it must have been for Mrs F during this time. We would like to thank her for her time and effort in bringing this complaint to our attention.

1. We have carefully considered Mrs F’s complaint about a GP Practice in Portsmouth (the Practice) about the care her late husband, Mr F, received between June 2023 and May 2024.

2. Mrs F complains the Practice did not respect the family’s wishes in relation to Mr F’s care at the end of his life. She says Mr F was given medication against his wishes and also given medication to hasten his death.

3. We are very sorry to hear about Mrs F’s concerns and appreciate this will have been a difficult time for her.

4. We would like to reassure Mrs F that we have not seen indications of failings in the Practice’s care and treatment of Mr F.

5. We hope our explanation below reassures Mrs F that we have considered her complaint appropriately and explains why we consider the Practice followed appropriate guidelines.