10. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have decided the Trust has already done enough to put right the impact of these events.
11. In its complaint response, the Trust explained that it gave Mr J pain relief on several occasions during the night but did not give him a syringe driver. A syringe driver is a small device that gives a continuous stream of medication in a syringe through a small tube under the skin.
12. Mrs J has described to us how upsetting it was to see Mr J distressed and how she and her family cannot forget about the memories of Mr J dying.
13. She explained how they had to keep asking a nurse for medication throughout the night. They feel let down that the Trust was not more proactive, as she is concerned that a palliative care consultant could have given Mr J different or additional medication or increased his dosage to make him more comfortable. A palliative care consultant is a doctor who specialises in making people who have life-limiting illnesses more comfortable by managing their symptoms.
14. The Trust reviewed Mr J’s records and acknowledged failings in Mr J’s care. It has apologised to Mrs J for her and her family’s experience. It apologised for not thinking of a syringe driver at the time and acknowledged it may have been a better way to keep Mr J comfortable.
15. The Trust explained what it has done to prevent this from happening again, including reminding staff there is always 24-hour support available from a palliative consultant. The Trust has discussed Mrs J’s experience with staff and met with staff involved in Mr J’s care to emphasise the importance of compassionate end of life care.
16. It has given training to staff including on deterioration in stroke patients and palliative care decision making. We think ensuring staff are equipped with the knowledge to support people at the end of their lives will help create a service where every patient feels seen, heard and comforted in their final moments.
17. The Trust has also explained that it monitors the effect of service improvements and has had no further complaints around end-of-life care on the stroke unit since February 2025.
18. After reviewing the Trust’s apology and service improvements we think it has taken suitable action to address Mrs J’s complaint. This is in line with our NHS Complaints Standards which say organisations should take action to identify learning and use it to improve services. As these are the outcomes Mrs J wanted to achieve through making her complaint, we do not propose to take any further action on Mrs J’s complaint.
19. Sadly, it is clear how deeply affected Mrs J and her family have been by what happened. Their commitment to improving services for other families is commendable and we hope the Trust’s response to Mrs J’s complaint will prevent other families from facing a similar situation in the future.