Chelsea and Westminster Hospital NHS Foundation Trust

4. Miss C complains about the care and treatment the Trust provided to her father, Mr F, during his hospital admission from mid-July to mid-August 2023, when he died. Specifically, she says the Trust:

• failed to acknowledge Mr F was at the end of life and implement palliative care • incorrectly placed Mr F in a surgical ward • inappropriately began antibiotic treatment for a gall bladder infection • inappropriately began active treatment for Mr F’s prostate cancer against his wishes • repeatedly asked Mr F to mobilise himself when he was too weak to do this.

5. Miss C says, as an impact of the Trust’s actions, her father did not receive palliative care at the end of his life. She says he therefore spent the final weeks of his life in pain and discomfort, and felt neglected, frustrated, miserable and hopeless. Miss C also says, Mr F felt humiliated and frustrated when staff repeatedly asked him to mobilise himself. Miss C told us fighting for the Trust to acknowledge Mr F was at the end of his life caused her considerable stress.

6. Miss C says the prostate cancer treatment caused Mr F to deteriorate. She says he was sleepier, did not want to eat, drink, or talk, and he described feeling terribly unwell. Miss C says Mr F died in a busy surgical ward surrounded by other patients and visitors. Miss C told us it was heartbreaking to find out the Trust had given Mr C such an aggressive treatment.

7. As outcomes to her complaint, Miss C would like systemic improvements.

8. Mr F had prostate cancer and heart failure. Mr F had a consultation with a urology consultant in June 2023. Following this he decided not to treat his cancer beyond controlling his symptoms.

9. Mr F attended the Emergency Department at the Trust following a fall in July 2023. The Trust discharged him after one day. He was readmitted two days later due to pain in his upper abdomen.

10. The Trust placed Mr F on a surgical ward throughout his admission and treated him with intravenous (IV) antibiotics for a gallbladder infection. The gallbladder is a small organ found under the liver which stores and releases bile produced by the liver. The Trust also started treatment for Mr F’s prostate cancer.

11. The Trust stopped active treatment of Mr F’s cancer at Miss C’s request. Mr F remained in hospital until he sadly died in August 2023.

Mobilisation

16. Miss C says the Trust repeatedly asked Mr F to mobilise when he was too weak to do so. She told us this included staff asking him to shift himself or move his bum.

17. BGS deconditioning guidance says deconditioning in older people with frailty may start within hours of lying on a trolley or bed. Deconditioning is the loss of normal function, and the guidance says staff should encourage patients to move.

18. NICE pressure ulcers guidance says people with significant limited mobility are at risk of developing pressure ulcers. The guidance says patients at risk of pressure ulcers should be repositioned at regular intervals.

19. The guidance also explains there are multiple risk factors for developing pressure ulcers. These include: significantly limited mobility, significant loss of sensation, a previous or current pressure ulcer, malnutrition, the inability to reposition themselves, and significant cognitive impairment.

20. The records show the Trust documented Mr F was mobile with a frame prior to his admission. The records show an orthopaedic physiotherapy review was conducted shortly after his admission which said he could mobilise as tolerated. This means he could move and be moved as tolerated, unless it caused too much discomfort. The records also show Mr F’s pressure areas were intact on admission.

21. The Trust assessed Mr F as being at high risk of pressure ulcers due to his risk factors. The records show the Trust encouraged Mr F to regularly change his positional while he was being nursed in bed. The Trust also referred Mr F for physiotherapy on admission. The records show he declined physiotherapy at times due to feeling tired. Physiotherapy input was then stopped in early August at his request.

22. Our nursing advisor told us it was appropriate to mobilise Mr F to prevent deconditioning and to encourage positional changes in bed to prevent pressure ulcers. They told us it was also appropriate for physiotherapy input to stop after Mr F expressed he did not want to mobilise and would prefer to remain bedbound in early August.

23. We note that when responding to Miss C’s complaint, the Trust acknowledged some shortcomings in the ward based care it provided to Mr F. It has implemented service improvements to address these. This included a nursing programme to revert back to more engaged conversations with patients and discussing Mr F’s case with the nursing team for learning.

24. We acknowledge and accept Mr F and Miss C found the language used by some staff upsetting when encouraging him to mobilise. We also acknowledge it was upsetting for Mr F to be encouraged to mobilise when he felt was unable to, particularly as he approached the end of his life.

25. The guidance we have seen says patients should be encouraged to move to prevent skin damage and associated pain. The records show Mr F was encouraged to move and it appears this stopped after he declined further physiotherapy input. It was in line with NICE pressure ulcers guidance and BGS deconditioning for the Trust to encourage Mr F to mobilise. We have not found any failings in the Trust’s actions here.

Inappropriate treatment and ward placement

26. Miss C says the Trust inappropriately placed Mr F on a surgical ward and began to treat him for a gallbladder infection despite him being end of life.

27. Cholecystitis is the inflammation of the gallbladder. If acute cholecystitis is suspected the NICE Cholecystitis guidance says a patient should be admitted for surgical assessment for cholecystectomy (gallbladder removal). It also says treatment may include intravenous fluids, antibiotics, and pain relief.

28. The records show the Trust admitted Mr F to a surgical ward from the Emergency Department (ED) and administered antibiotics to him. Mr F had been brought back to the ED due to pain in his upper abdomen and a CT scan reported findings that could be significant for acute cholecystitis. The CT scan report explained the gallbladder was swollen (oedematous) and contained a type of harden gallstones (calcified gallstones).

29. Our surgical advisor told us it was entirely appropriate for Mr F to be admitted to a surgical ward as it was thought his pain was due to cholecystitis. The also told us when the Trust started antibiotics on admission, Mr F’s, or his family’s, wishes regarding end of life care and treatment were not clear.

30. Our surgical advisor noted that being placed on a surgical ward did not impact the care available to Mr F. They told us the records show Mr F still received input from the palliative care team, physiotherapy, and occupational therapy input.

31. NICE Cholecystitis guidance says cholecystitis is treated with antibiotics and there should be a surgical assessment for cholecystectomy. It was therefore in line with the NICE Cholecystitis guidance for the Trust to admit Mr F to a surgical ward for assessment, and to prescribe antibiotics for cholecystitis. We have not found any failings in the Trust’s actions here.

32. We appreciate how Mr F’s placement on a surgical ward raised concerns for Miss C about the level of care he was receiving. We hope our explanation reassures Miss C that the care he received was not impacted by this.

33. Miss C also told us the Trust inappropriately began to treat Mr F for prostate cancer against their wishes. She said she is unsure what the Trust communicated to Mr F before starting treatment. She believes he either did not hear, misunderstood, or did not remember previous conversations about the drug used.

34. The NICE prostate cancer guidance says providers should ensure palliative care is available when needed and is not limited to the end of life for metastatic prostate cancer. It also says providers should discuss personal preferences for palliative care as early as possible with patients, their partners and carers. Treatment and care plans should be tailored accordingly.

35. The records show the Trust administered two 50mg doses of Bicalutamide (which used to treat prostate cancer) to Mr F. No further doses were given after Miss C asked for treatment to stop at the beginning of August.

36. Our urology advisor told us the records show Mr F was not end of life when the Trust started treatment for his prostate cancer. They also confirmed Mr F’s records do not indicate he was not for active treatment when treatment was started and there was no advance decision to refuse treatment in place.

37. Mr F’s records show a urology review took place, there was a discussion with his next of kin, and a palliative care referral was made at the end of July. They also show a further urology discussion and multi-disciplinary team discussion a week later.

38. Mr F’s records do not show he consented or refused the treatment the Trust started for his prostate cancer. Our urology advisor explained this is sufficient for treatment to have started. The records show the Trust did not perform a bone scan on Mr F at Miss C’s request.

39. Miss C informed the Trust they did not want active treatment for Mr F’s prostate cancer in early August. Active treatment for Mr F’s cancer was stopped following this conversation. Mr F was assessed to have capacity and it was documented a few days later that he had declined treatment for his prostate cancer.

40. The Trust did acknowledge some shortcomings in starting treatment for Mr F’s cancer. It explained it had reviewed Mr F at a virtual outpatient appointment, before starting medication. It recognised it had not discussed this with Mr F or his family, and it apologised for this.

41. The Trust has implemented service improvements to address these shortcomings. It now requires any patient on an alternative (cancer or elective) outpatient pathway to have their notes reviewed and, if required, a ward review from the on-call team. Medications will not be prescribed without first discussing it with a patient or next of kin. Outpatient appointments will also be rescheduled when a patient is too unwell to attend.

42. NICE prostate cancer guidance says treatment for metastatic prostate cancer should not be limited to end of life. The records show Mr F had capacity and do not note he refused treatment when it was initially provided. The records also show the Trust stopped treatment at Miss C’s request and later documented Mr F’s wish to have no further treatment for his cancer.

43. It was in line with NICE prostate cancer guidance for the Trust to treat Mr F’s cancer and we have seen no evidence to show treatment was started against his wishes. We have not found any failings in the Trust’s actions here. We do not doubt how upsetting it was for Miss C to find out the Trust had started treatment for Mr F’s cancer and accept this must have been incredibly stressful for her. We hope Miss C is reassured the Trust has taken action to improve the service it provides here.

Palliative Care

44. Miss C says the Trust failed to acknowledge Mr F was at the end of his life and implement palliative care. She told us the Trust ignored and did not follow up on her requests for palliative care.

45. NHS end of life information explains end of life care is support for people who are in the last months or years of their life. Where a patient has capacity, GMC End of Life guidance says doctors and patients should make an assessment of their condition and identify options for treating or managing their condition. Patients should be allowed to decide between options, including opting to refuse treatment.

46. GMC End of Life guidance acknowledges the role people close to patients play in ensuring they receive high quality care in the end of life stage. It says treatment options should be discussed with them, with patient consent and, as far as possible, their needs for support are met and their feelings are respected. The focus of care must remain on the patient.

47. The records show Mr F was thought to have cholecystitis (inflammation of the gallbladder) when he was admitted. It is recorded that Mr F said he did not want any surgical interventions near the start of his admission, and the Trust began to treat him with antibiotics. Notes from his urology consultation in June show the plan was for symptom control of his prostate cancer going forward.

48. Our surgical adviser told us Mr F was not for end of life care when the Trust admitted him. They explained that Mr F and Miss C’s wishes did not mean he was on the end-of-life pathway at this time as he was at no imminent risk of dying.

49. The records also suggest the Trust took Miss C’s requests for palliative care seriously, and it referred Mr F for palliative care input. Mr F was seen by the palliative care team on multiple occasions. The Trust made a referral for a palliative review the same day Miss C requested one at the end of July.

50. The records show discussions in early August where Mr F and Miss C stated they only wanted palliative involvement going forward. Mr F’s records show the palliative care team stated their input was not required in early August. The Trust also arranged for Mr F to be reviewed by the palliative team again when it was decided he would be discharged.

51. The Trust planned to discharge Mr F on a fast-track pathway. This is where a patient at the end of their life is discharged home or to an appropriate facility rapidly. This planning took some time as Mr F could not be discharged home without a higher level of support.

52. Our surgical advisor highlighted that it can be very difficult to identify when someone is coming to the end of their life and this can take some time to become apparent. They note Mr F deteriorated quite suddenly as the Trust was making plans to discharge him. They also noted that not all patients require specialist palliative care input.

53. NHS end of life information does not say end of life care requires specialist palliative input, but we can see the palliative team were involved in Mr F’s care. The records show the Trust was aware Mr F was coming to the end of his life and it provided care in line with GMC End of Life guidance.

54. The Trust acknowledged some shortcomings in staff recognising Mr F was at the end of his life. It has implemented service improvements to address these. The Trust has provided further training on palliative care to the staff on the ward Mr F was treated on. Palliative care is now also part of junior doctors rotational training.

55. The Trust has acknowledged there were shortcomings in the care it provided to Mr F. We have seen no evidence that the care provided by the Trust fell so far below the standard set out in the guidance to be considered a failing. We have seen no evidence the Trust did not follow up on Miss C’s requests for palliative input. We have not found any failings in the Trusts actions here.

56. We are sorry to hear of the circumstances leading to Miss C’s complaint to us. We acknowledge the distress she has experienced regarding her concerns about the level of care Mr F received. We hope she is reassured that the evidence shows the Trust has made some improvements as a result of her complaint. Based on the evidence, we have found no failing in the Trust’s actions here.

57. We thank Miss C for bringing her complaint to us and hope we have been able to fully explain how we have reached our decision.

1. We are sorry to hear of the circumstances of Miss C’s complaint. She has told us of her concerns about how Chelsea and Westminster Hospital NHS Foundation Trust (the Trust) treated Mr F at the end of his life. We acknowledge the distress Miss C and Mr F experienced.

2. We have carefully considered Miss C’s complaint about the Trust. We have found no failings in the Trust placing Mr F on a surgical ward or beginning treatment for his gallbladder infection and prostate cancer.

3. We have found no failings in the Trust acknowledging Mr F was end of life and implementing palliative care or asking Mr F to mobilise. This report fully explains the reasons for our decision.