4. Ms A complains about how clinicians at the Hospital discharged her mother in December 2024 without giving her all the medication she needed and with no nursing support at home.
5. Ms A says her mother was nearing the end of her life and was left in pain and discomfort for ten days. She explains how this led to additional distress for the family at a time when they were already upset. Ms A wants the Trust to accept accountability for these failings. She also seeks a financial remedy.
6. Mrs D had a history of angina and chronic kidney disease. In October 2024 she saw her GP because she was concerned about pain in her upper abdomen. They arranged an ultrasound scan which did not show any signs that were suspicious of cancer.
7. On 5 December 2024 Mrs D saw her GP again. She had worsening jaundice and abdominal discomfort. The GP was concerned and asked her to go to the Hospital. Doctors at the Hospital admitted Mrs D for investigations. These investigations showed she had pancreatic cancer that had spread to other parts of her body. A doctor met with Mrs D and Ms A to explain that the cancer was incurable, and the focus would be on providing palliative care.
8. Doctors discharged Mrs D from the Hospital on 19 December 2024. Clinicians at the Hospital referred her to a community care organisation’s respiratory service to supply home oxygen. On 29 December the local hospice contacted the care organisation’s integrated care team (ICT). Nurses from the out of hours service visited her the next day, and a palliative care nurse saw her on 31 December 2024. Sadly, Mrs D died on 4 January 2025.
9. Ms A complained to the Trust in June 2025. The Trust replied on 7 August 2025. Ms A remained dissatisfied, so she complained to us.
Nursing support at home
12. Ms A complains that her mother needed help at home and that clinicians did not arrange for this to be provided for her. She believes there should have been a referral to the local hospice, but this did not happen.
13. The Quality Standard includes guidance on how healthcare professionals should plan care in advance with people who are approaching the end of their life. It says organisations should ensure they have systems in place to give adults approaching the end of their life opportunities to have discussed about advance care planning.
14. The NMC Code contains the professional standards that nurses are expected to follow. It says nurses must listen to people and respond to their preferences and concerns. They must respect the level to which people receiving care want to be involved in decisions about their own health. They must also respect a person’s right to refuse care and treatment.
15. The clinical records show that, on 16 December 2024, an occupational therapist reviewed Mrs D on the ward. They noted she was able to understand what was being discussed. Mrs D said she wanted to be discharged to her daughter’s house. She declined to have any support from carers. The therapist explained that as Mrs D’s health deteriorated this might change and she might not be able to look after herself. Mrs D said there would always be someone with her and if her daughters needed support from carers they would contact the appropriate team in the community at the time.
16. Before Mrs D left the Hospital the ward team completed a palliative care assessment. They noted she was keen to go home and had no symptoms. They said she was well supported by her family. They noted that home carers were not required and there was no requirement to contact the Hospice at Home team. Mrs D required home oxygen and staff at the Hospital arranged this for her.
17. Further records from 19 December 2024 show the Trust notified Mrs D’s GP that she was being discharged and that she needed to start on oxygen. This started the following morning. The GP records noted Mrs D ‘refused any equipment or care package’ when she was discharged from the Hospital.
18. On 29 December 2024 Mrs D’s GP made a referral to the local Hospice for care at home. The Hospice confirmed to us that this was the only request it had received from clinicians relating for the Hospice at Home team for Mrs D.
19. The Clinical Adviser told us that a hospice referral can be made at the same time as arrangements are being made to go home. This enables a seamless transfer to a hospice from a home if necessary. In this case Mrs D declined this offer of support.
20. The evidence shows that clinicians at the Hospital had discussions with Mrs D about advance care planning. They clearly took her wishes into account. There is nothing to suggest that Mrs D wanted a referral to the local hospice or that a referral to the Hospice at Home team was needed.
21. We recognise Ms A has a different recollection of events. We are persuaded by the available records from different organisations, which show that Mrs D declined nursing support at home. There is no suggestion Mrs D lacked capacity to make such a decision.
22. We find nurses followed the Quality Standard and the NMC Code. They discussed arrangements with Mrs D and respected her wishes. We can see no evidence of any failings in this respect.
Medication
23. Ms A complains that clinicians gave her a bag of medication for her mother when she left the Hospital, but this did not include all the medication she needed. She says this meant her mother experienced unnecessary distress towards the end of her life. Ms A told us she could not recall which medication was missing.
24. The End of Life Guideline explains how clinicians should use an individualised approach to prescribing medication for people who are likely to need symptom control in the last days of life. It says they should ensure that suitable medications are prescribed as early as possible.
25. The NMC Code says nurses must ensure they deliver the fundamentals of care effectively. It says nurses must deliver treatment or care for which they are responsible without any delay.
26. The clinical records show that when Mrs D left the Hospital nurses observed that she had no symptoms and was keen to get home. They noted she did not yet need end of life medication, but it had been prescribed should it be needed.
27. The discharge summary in the clinical records shows doctors prescribed lorazepam for Mrs D among several other medicines on 19 December 2024. GP and community nursing records show lorazepam was not included in the medication given to her on discharge. Lorazepam is used to manage anxiety, agitation and restlessness. We can see that Mrs D had access to morphine and paracetamol for pain.
28. A GP later prescribed lorazepam when visiting Mrs D at home on 29 December 2024. The GP records show Mrs D starting to have pain in her abdomen and back on 28 December. She had been taking morphine and paracetamol, as prescribed and administered by clinicians at the Hospital, but Ms A said this did not last long enough.
29. The clinical records show Mrs D had a syringe driver in place to deliver regular pain relief at home. Community nurses set up the syringe driver for Mrs D on 1 January 2025.
30. The records do not suggest the omission of lorazepam caused any issue for the first nine days following Mrs D’s discharge from the Hospital. The indications are that her pain became a significant problem only on 28 December 2024 and she already had medication for pain at that point. It seems likely that Mrs D also became agitated and restless at that time. This means that for around one day she experienced distressing symptoms that may have been avoided if lorazepam had been provided.
31. We can see that clinicians at the Hospital prescribed Mrs D’s take home medications appropriately in line with the End of Life Guideline. But they omitted lorazepam in error. They fell below the standards expected in the NMC Code by not delivering the fundamentals of care effectively.
32. The Clinical Adviser told us the omissions would have led to Mrs D having uncontrolled symptoms which would have been distressing for her and her family. This distress could have been avoided had the error not occurred. Our view is that the avoidable distress may have lasted for around one day. However, it is also possible that even had she taken the medication Mrs D may still have experienced the symptoms.
33. We find that nurses fell below the relevant standards when they omitted lorazepam from Mrs D’s prescribed discharge medication. This meant Mrs D experienced agitation and distress for around one day that may have been avoided or reduced. Her family’s distress may also have been avoided.
34. The Trust apologised to Ms A in its complaint response for the missing medication. It said this was due to human error. Nurses had discussed the incident at a ward meeting in July 2025. They had been reminded of the importance of checking medication at the time of discharge. The Trust apologised for Mrs D’s poor experience.
35. We consider the Trust has accepted accountability for the failing we have seen. We are satisfied the Trust’s actions are sufficient and it would not be appropriate for us to recommend a financial remedy, particularly as the incident may have had a limited impact for a relatively short period of time.
36. The last days of Mrs D’s life were clearly incredibly distressing for her family. Ms A has told us how this continues to be a source of distress for them. We have carefully considered all the evidence, and we have seen no evidence of any significant failings by clinicians from the Hospital. We are also satisfied that the Trust has taken appropriate action to demonstrate learning relating to the omission of lorazepam. We do not uphold Ms A’s complaint.
1. Ms A complains about aspects of her mother, Mrs D’s, care at the Hospital (part of the Trust). Her concerns relate to the arrangements for care at home following her discharge from the Hospital. Mrs D sadly died shortly after these events. We can see how devastating these events have been for Ms A and her family. We offer our sincere condolences to them for their loss.
2. We have seen evidence that clinicians omitted some of the medication Mrs D needed when they discharged her from the Hospital. We can see the Trust has already accepted this failing and taken appropriate action. We find there were no failings relating to the nursing support clinicians from the Hospital arranged for Mrs D at home.
3. We do not uphold Ms A’s complaint.