Northumbria Healthcare NHS Foundation Trust

The Practice

4. Mr E complains about the care and treatment the Practice provided to his mother, Mrs G. Specifically, Mr E complains the Practice:

• failed to investigate Mrs G’s symptoms of a bad back, loss of appetite, constipation, and a change of taste when she attended during 2023 • failed to inspect Mrs G’s mouth when she complained of lack of taste and appetite in July 2023 • should have sent Mrs G for a CT scan earlier than August 2023 • gave Mrs G an appointment with a physician associate when she was expecting to see a GP on 4 July 2023 • failed to respond appropriately and promptly to Mr E’s complaint in 2024 regarding Mrs G’s treatment.

5. Mr E says the Practice’s failure to investigate Mrs G’s symptoms and delay in providing her with a CT scan resulted in a delay in her being diagnosed with pancreatic cancer, causing her to miss the opportunity to participate in chemotherapy treatment. Mr E says the Practice’s failure to inspect Mrs G’s mouth meant she suffered from oral thrush for an extended period, which reduced her ability to eat and drink. Mr E says this compromised Mrs G’s physical condition, which caused her to respond poorly to the medication she was given for the pancreatic cancer.

6. Mr E says when Mrs G realised she was having an appointment with a non-GP, she was surprised and did not feel comfortable sharing all the details of her condition with them. This resulted in further delay in her diagnosis. The Practice’s delay in responding to his complaint caused him stress and emotional distress, and prolonged his grieving process following his mother’s death.

7. Mr E would like financial compensation for unnecessary distress caused to his family by the Practice’s failings. Mr E would like service improvements to address the Practice’s failings.

The Trust

8. Mr E complains about the care and treatment provided by the Trust to Mrs G between August 2023 and October 2023. Specifically, Mr E complains the Trust failed to:

• gather sufficient information about his mother’s medication history • give his mother an appropriate amount of medication given her history of taking very little medication previously, and respond promptly and appropriately to his mother’s reaction to the medications • look in Mrs G’s mouth when she reported a loss of taste.

9. Mr E says the Trust gave his mother too much medication too soon because it did not know his mother had previously taken very little medication. He says the Trust’s overmedication of his mother resulted in her having severe side effects between August 2023 and October 2023, significantly decreasing the quality of her life when she only had a few months left to live. He also says the medications made her too sick to be able to attempt chemotherapy, which could have extended her life. In addition, Mr E says the Trust did not respond promptly to Mrs G’s reactions to the medications, leaving her and her family in extreme emotional distress while she was vomiting black vomit, feeling intense pain, and stuttering. Had the reactions to the medications been resolved sooner, Mrs G might have been able to try chemotherapy, which could have extended her life.

10. Mr E says the Trust’s failure to look in Mrs G’s mouth resulted in a delay in identifying and treating Mrs G’s oral thrush. The oral thrush decreased her appetite, which meant she did not have enough food in her stomach to be able to tolerate the medications. If the Trust had identified and treated the oral thrush sooner, she would have had less significant side effects from the medication.

11. Mr E seeks financial compensation for the distress his mother and her family experienced due to the effects of overmedication, and being deprived the opportunity to have chemotherapy.

12. Mrs G was diagnosed with advanced pancreatic cancer in August 2023 at the age of 74. She had attended multiple appointments at the Practice in the six months before her diagnosis complaining of back pain, loss of appetite, constipation, and a change of taste.

13. Mrs G began palliative treatment for the pancreatic cancer in August at the Trust, and was admitted to hospital multiple times during September and October with intense nausea and pain. By late October her symptoms had stabilised and she was able to remain at home.

14. Mrs G sadly died of pancreatic cancer in March 2024.

15. Mr E complained in writing to the Practice and the Trust on 14 January 2024. The Practice responded to his complaint in April, and Mr E then asked additional questions and requested a meeting on 25 April. After two attempts to hold a meeting, both of which the Practice cancelled, Mr E did not hear anything further from the Practice. After intervention by PHSO in November 2024, Mr E received a final written response from the Practice on 20 November.

16. Mr E received a final written response from the Trust on 30 August 2024.

The Practice - GP investigations during appointments between January and July 2023

20. Mr E says the Practice did not act on his mother’s symptoms of a bad back, loss of appetite, constipation and a change to her taste between January and July 2023. He says this caused a delay in her being diagnosed with pancreatic cancer.

21. Mrs G attended appointments at the Practice on 17 January, 16 June, 23 June, 4 July, and 31 July. On 17 January, Mrs G discussed blood test results and weight gain with the GP. On 16 June, her medical records reflect she reported several weeks of back and abdominal pain. The GP diagnosed a rib sprain, prescribed painkillers, and advised her to return if the pain worsened or did not improve. She returned the next week with ongoing pain which the GP diagnosed as Musculo-skeletal and arranged a chest x-ray to rule out other pathology. The x-ray results were normal.

22. On 4 July, Mrs G reported ongoing back and abdominal pain, and constipation. The clinician examined her abdomen and found it normal, and ordered a bowel cancer stool test. Medical records reflect Mrs G denied weight loss, blood in her bowels, new onset acid reflux, and difficulty swallowing. Mrs G returned to the Practice on 31 July again reporting back and abdominal pain, bowel problems, a change of taste, and significant weight loss of 7 kilograms since January. The GP arranged an urgent CT scan.

23. We cannot reconcile the significant weight loss noted in the medical records on 31 July with the medical notes earlier in the month which record there was ‘no change to weight’. Our adviser noted it is not common practice to weigh a patient unless they report a change in weight. There is no indication Mrs G reported weight loss until 31 July.

24. The GMC Guidelines state clinicians must assess a patient’s conditions and promptly arrange investigations, treatment, and referrals. NICE Cancer Guidance directs clinicians to refer patients for an urgent CT scan to assess for pancreatic cancer in people aged over 60 with weight loss and any of the following: diarrhoea; back pain; abdominal pain; nausea; vomiting; constipation; newonset diabetes.

25. Mrs G was 73 during the relevant period. The NICE guidance to refer for an urgent CT scan would apply to her care if she presented with both weight loss and one of a variety of symptoms, including back or abdominal pain and constipation. She first attended the Practice reporting both weight loss and abdominal pain along with constipation on 31 July, at which point the GP immediately referred her for a scan.

26. Our adviser reviewed the steps the GP took to investigate Mrs G’s symptoms at the earlier appointments and found them to be clinically appropriate and in line with GMC guidance.

27. We can see the Practice acted in line with guidance during Mrs G’s appointments between January and July 2023. As a result, we will not continue to investigate this aspect of the complaint.

The Practice – Inspection of Mrs G’s mouth

28. Mr E complains the Practice failed to inspect Mrs G’s mouth when she complained of lack of taste and appetite. He believes it should have examined her and treated her oral thrush.

29. Mrs G’s medical records reflect she first mentioned her taste had changed on 31 July during a GP appointment. Her medical records show no mention of pain or white patches in her mouth at any of her appointments. The GP who saw Mrs G on 31 July did not examine her mouth.

30. NHS Oral Thrush Guidance says the main indication of oral thrush is painful white patches in the mouth. Symptoms include an unpleasant taste and pain in the mouth, and difficulty eating and drinking. There is no standard or guidance which says whether the mouth should be examined if a patient complains of a change in taste. Change of taste is a common symptom and there is no specific guidance as there are numerous potential causes.

31. As there is no guidance stating GPs should examine patients complaining of a change in taste, and Mrs G did not disclose any other symptoms which would indicate oral thrush, we have not identified any indication of a failing and will not consider this aspect of the complaint further.

The Practice – Timing of CT scan 32. Mr E says the Practice should have referred Mrs G for a CT scan earlier. He believes this would have resulted in an earlier diagnosis. Earlier in this statement, we have seen the Practice acted in line with guidance in each of Mrs G’s appointments when it assessed her and referred her for other investigations. We have seen when Mrs G attended the Practice complaining of weight loss, lower back and abdominal pain, the Practice referred her for an urgent CT scan in line with guidance.

33. We have not seen any indication Mrs G should have been referred for a CT scan sooner.

The Practice – Appointment with Physician Associate 34. Mr E complains his mother attended an appointment where she believed she was going to see a GP, but instead the appointment was with a non-GP. Mr E stated his mother told him she was not as forthcoming with sensitive health information when she realised she was not being seen by a GP, and this was a lost opportunity for her cancer to be diagnosed sooner.

35. Mrs G’s medical records reflect she attended an appointment on 4 July with a physician associate. Mr E stated he believes this was the appointment his mother mentioned.

36. The Practice told us Mrs G booked this appointment the same day. The Practice could not provide us with a recording of the call. During the appointment, medical records reflect Mrs G reported ongoing back pain, new abdominal pain, and constipation. The physician associate discussed Mrs G’s medical history, did a physical examination, formulated a care plan, and requested tests. The physician associate stated she performed these duties whilst being supervised by a GP.

37. There is no evidence Mrs G mentioned anything to the Practice about not being able to see a GP at this appointment nor did she ask for another appointment with a GP immediately following this appointment.

38. The NHS Choice Framework states patients can choose to see a particular healthcare professional, and the practice must make every effort to meet a patient’s preferences. The NHS Constitution also states patients have a responsibility to ‘provide accurate information about [their] health, condition and status.’

39. We do not have contemporaneous evidence about what Mrs G was told about who would be seeing her during this appointment, and we do not have Mrs G’s account of what she was told, or about what additional information she would have provided had she been able to see a GP rather than a physician associate.

40. We understand Mrs G may have been surprised or disappointed she was not seeing a GP during this appointment. It was still her responsibility to provide accurate information about her health concerns with her clinician. Notes from the appointment reflect she did share some relevant information about her health with the physician associate, including about sensitive topics such as her digestion. Additionally, we do not see any indication she told the Practice she was dissatisfied with seeing a non-GP at this appointment or she immediately requested an appointment with a GP.

41. We see no indications of failing with this aspect of the complaint and therefore will not continue to investigate it.

The Practice - Complaint Handling 42. Mr E complains about the way the Practice handled his complaint and says the Practice did not respond to the specific points he raised, took too long to respond, and offered him a meeting to discuss his complaint and then cancelled the meeting without offering to reschedule it.

43. Mr E complained to the Practice in writing on 14 January 2024. The Practice responded on 17 April. The letter was signed by the Practice Manager, who acknowledged the delay, apologising and taking personal responsibility. The response answered the concerns in the complaint and signposted him to PHSO. It offered a meeting with a GP at the Practice. Mr E responded with further questions and accepted the offer of a meeting.

44. The Practice arranged the meeting at a time when Mr E could not attend. The Practice then arranged another meeting but cancelled on the morning of the appointment. The Practice did not try to set up another appointment. Mr E then complained to PHSO. Both PHSO and Mr E followed up with the Practice, who sent a final written response on 20 November.

45. The NHS Complaint Standards state a practice must send the complainant a written response within six months from the date of the complaint, signed by the responsible person, responding to the complaint, stating any actions the practice will take, and details of the complainant’s right to take their complaint to the PHSO. Additionally PHSO’s Principles of Good Administration state public bodies should ‘do what they say they are going to do’ and keep their commitments or explain why they cannot do what they have committed to do.

46. The Practice responded to Mr E’s complaint four months after he submitted it, within the six-month timeline specified in the NHS Complaint Standards. The Practice acted in line with guidance by providing a signed, written response to each of the questions raised and signposting Mr E to the PHSO.

47. When the Practice cancelled Mr E’s meeting with the GP, it should have followed up promptly to reschedule. Additionally, the Practice did not respond to Mr E’s follow up questions until 20 November, after it was prompted to do so by the PHSO. These actions were not in line with the NHS Complaints Regulations and the Principles of Good Administration, which state organisations should do what they say they are going to do. Thus, we can see an indication of failing.

48. We understand the cancellations and delays have caused Mr E frustration, and to feel the Practice did not take his complaint seriously. This equates to Level 1 on our Severity of Injustice Scale. Level 1 includes harms such as annoyance, frustration, or inconvenience arising from an isolated instance of service failure, and where there is no ongoing impact. In such cases, we consider an apology to be appropriate.

49. We see the Practice apologised for the delays and cancellations in arranging the meeting in its letter of 20 November. We consider Mr E’s injury due to these failings has been remedied. We have not seen an unremedied injustice with respect to this aspect of the complaint and so we will not investigate it further.

The Trust – Gathering information about Mrs G’s medication history 50. Mr E complains the Trust did not gather sufficient information about Mrs G’s medication history during her initial consultation regarding her pancreatic cancer in August 2023. He states because of this failing, the Trust was unaware Mrs G had not taken much medication previously and might be quite sensitive to medication. As a result, Mr E states the Trust gave her inappropriately high doses of medication when she began palliative care for her pancreatic cancer. This resulted in her having intense nausea.

51. On 22 August 2023, Mrs G attended an initial consultation with a gastroenterology clinical research fellow about her potential pancreatic cancer diagnosis. The letter summarizing the appointment described the symptoms Mrs G reported, along with the medications she had tried and their effect. The letter noted her severe back pain had not been helped by ‘any of the painkillers which [she had] tried including Codeine and Ibuprofen gel’. The letter also stated she tried anti-nausea medication, but this had not helped, and she was struggling to sleep.

52. Mrs G’s medical records also reflect she was assessed by a community nurse on 30 August, who reported Mrs G’s medications. The notes reflect Mrs G declined to take prescribed anti-nausea medication due to potential side effects and was actively vomiting. On 31 August, Mrs G’s medical records reflect that a different community nurse attended Mrs G’s home and spent an hour with Mrs G and her husband discussing in detail Mrs G’s medical history and current issues and adjusted her medication to address the nausea and pain.

53. On 4 September, Mrs G was admitted to hospital with severe pain and black vomit. Following her admission, the palliative care team in the hospital adjusted her medications to stabilise her symptoms.

54. NICE medicines optimisation guidance states a medication review is recommended for older people, and should consider all medicines the patient is taking, the patient’s views and concerns regarding their medicines, how safe the medicines are, how well they work for the patient, whether the person has any risk factors for developing adverse drug reactions, and any monitoring which may be needed.

55. The gastroenterologist appropriately reviewed Mrs G’s medications, as she was in one of the groups (older people) which the guidelines specify for medication reviews. The gastroenterologist considered Mrs G’s understanding of the medications she had tried and their effects, and mentioned she only took one medication (Bisoprolol) regularly. Mrs G’s medical records do not refer to allergies or intolerance to particular medications. The medical history outlined in the letter is in line with guidance.

56. Additionally, we see the community nursing team took time to gather information about Mrs G’s medical history and used this information to provide her with appropriate medication for her symptoms.

57. We do not see any indications of failing in the way the Trust gathered Mrs G’s medication history. We will not continue to investigate this aspect of the complaint.

The Trust - Titration of Mrs G’s medication 58. Mr E complains the Trust provided Mrs G with inappropriate amounts of medication based on her history of taking very little medication. He complains the level of medication the Trust gave her initially caused her extreme nausea and black vomiting, which sapped her strength by preventing her from sleeping. He complains the Trust did not respond promptly to Mrs G’s reactions to the medications. Mr E states the medications the Trust provided Mrs G prevented her from being well enough to benefit from chemotherapy or other treatment.

59. At Mrs G’s initial consultation with the gastroenterology clinical research fellow on 22 August 2023, the doctor prescribed her anti-nausea medication, a painkiller called Amitriptyline, and 5 to 10 mls of oral morphine every four hours as required for pain.

60. On 30 August Mrs G met with a community nurse, who reported she was taking the Amitriptyline. The nurse noted the GP advised Mrs G to increase to 20mg but she was reluctant to do so as she associated vomiting with taking this medication. The nurse reported Mrs G was prescribed to take oral morphine as needed, and an anti-nausea medication. The nurse noted Mrs G had declined to take this due to the list of potential side effects, and was actively vomiting. The nurse also noted Mrs G had disrupted sleep due to the pain.

61. On 31 August Mrs G met with a different community nurse, who changed Mrs G’s medications, prescribing a lower amount of oral morphine, adding medications to reduce inflammation, pain, acid reflux, indigestion, and nausea. The nurse also diagnosed her oral thrush and prescribed medication to treat this.

62. On 4 September Mrs G was admitted to hospital with nausea and had been bringing up black vomit overnight. She also had intense back pain, difficulty with bowel movement and fatigue. The palliative care team suggested due to the nausea, Mrs G had not been absorbing her medication and proposed administering it via syringe driver.

63. The next day Mrs G reported feeling much better, with no nausea, more appetite, and no pain. Over the following days, the palliative care team worked to adjust her medications to stabilize her symptoms, and then to transition her back to taking medication orally so she would not need to use a syringe driver at home.

64. On 12 September the team restarted Mrs G on oral medication and stopped delivering it via syringe driver. The next day Mrs G felt more pain and nausea, but by 14 September she had stabilized and was discharged home.

65. Mrs G was admitted back into hospital on 16 September vomiting black vomit and with constant back pain. She was placed back on syringe delivery of her medications. Once her symptoms stabilized, she was discharged home on 19 September with a plan for syringe rather than oral delivery of medications.

66. Mrs G managed for a time at home, but began to develop nausea, more pain, and speech difficulties. Dr T noted speech difficulties during his appointment with Mrs G at the oncology outpatient clinic on 28 September (‘Marked stutter and involuntary facial movements.’) Dr T stated he suspected the cause of the stuttering was either Mrs G’s cyclizine or an ‘organic cause’. He said it would be difficult to change Mrs G’s cyclizine while she was an outpatient given her concern about the vomiting coming back, and suggested this would be dealt with most appropriately via admission to the Palliative Care Unit.

67. After this appointment, on 29 September the cyclizine was stopped and it appeared to help with the stuttering, however her nausea and vomiting worsened. A bed in the Palliative Care Unit became available on 2 October and Mrs G was admitted to hospital for management of her medication and symptoms. During this period, the palliative care team adjusted her medications, and she was discharged on 13 October.

68. After she was discharged on 13 October, her symptoms and medications were managed at home.

69. NICE End of life care guidance states clinicians should assess patients holistically, and discuss with them any changes which could optimise their care and improve their quality of life. There is no set regimen for a patient’s symptoms. Different medications will need to be tried, however, a patient with pancreatic cancer would typically be prescribed a strong opioid painkiller, anti-nausea medication, and a laxative. It is common to prescribe oral morphine and metoclopramide to patients with symptoms similar to Mrs G’s.

70. NICE opioid guidance recommends for elderly or frail people to start with 2mgs of morphine every four hours plus as needed for breakthrough pain. The guidance advises using cautious dose titration in the elderly or frail, as this can help to reduce initial drowsiness, confusion, and unsteadiness. There is no specific morphine dose which is correct for a given clinical scenario. All patients need to be individually assessed. Signs a patient is being given too high a dose of opioid painkiller include hallucinations and twitching. NICE guidance on opioids also suggest prescribing a laxative.

71. Mrs G was initially prescribed medication to help her symptoms of pain and nausea. It appears Mrs G was reluctant to take her anti-nausea medication, which may have contributed to her feelings of nausea.

72. Additionally, our adviser noted the prescription initially provided Mrs G on 22 August for oral morphine of 5 to 10 mls every four hours is more than the NICE guidance recommended dose for Mrs G’s age group. However, our adviser stated the starting dose was reasonable, based on the following considerations: Mrs G had experienced back pain for four months which had not been resolved by any painkillers including Codeine and Ibuprofen gel; Mrs G showed no evidence of opioid toxicity after the initial morphine dose was prescribed, such as twitching or hallucinations; and the notes from 30 August, when Mrs G was visited by a community nurse, indicate the prescribed level of medication did not appear to be controlling her pain.

73. We see no indication of failing in the initial medication the Trust provided to Mrs G prior to her admission to hospital on 4 September.

74. After Mrs G was admitted to hospital on 4 September, the palliative care team worked to alter her medications promptly to control her symptoms, trying different medications and dosages to attempt to optimise control of her symptoms. Mrs G was reviewed regularly by her clinicians, who changed her medications as needed when her symptoms were not stable. During her several stays in the hospital specialist palliative care unit, clinicians focused on stabilizing her symptoms, with the goal of being able to return her to her home where she stated she was most comfortable.

75. Ultimately after a period of initial instability during August, September, and October, Mrs G’s symptoms remained stable for several months and she was able to remain in her home. We can see this period was extremely distressing and frightening for Mrs G and her family given the seriousness of the diagnosis. However, our adviser stated there are no specific standards and guidelines with regards to how long it should take for a patient’s symptoms to be controlled. Some patient’s symptoms improve quickly; for others their symptoms are never under control. We see the clinicians who cared for Mrs G acted promptly, and were in frequent communication with her and her family about a care plan which prioritised her needs. We see no indication the care provided by the Trust during this period was inconsistent with applicable standards and guidance.

76. Mr E expressed concern the medication provided by the Trust made Mrs G so unwell that she was not able to attempt chemotherapy treatment which could have extended her life. As noted above, we have seen the Trust took reasonable steps to stabilise Mrs G’s symptoms. Our adviser noted pancreatic cancer is not very sensitive to chemotherapy, and Mrs G had incurable cancer at diagnosis so any chemotherapy would not be given with the aim of cure. Oncology colleagues need to make decisions about whether potential benefits (such as some improvements in quality of life, or prognosis) are worth the risk of toxicity, particularly where the patient is frail with unstable symptoms. We see no indications the actions of the Trust caused Mrs G to miss an opportunity for chemotherapy treatment.

77. We see no indications the Trust failed to provide care in line with guidance, and we will not continue to investigate this aspect of the complaint.

The Trust - Inspection of Mrs G’s mouth

78. Mr E complains the Trust failed to inspect Mrs G’s mouth during her initial consultations in August 2023. Mr E says this failing caused a delay in identifying and treating Mrs G’s oral thrush. The oral thrush decreased her appetite, which meant she did not have enough food in her stomach to be able to tolerate the medications. If the Trust had identified and treated the oral thrush sooner, she would have had less significant side effects from the medication.

79. The letter from Mrs G’s first appointment at the Trust on 22 August does not mention she reported a dry mouth, change of taste, or red and white patches in the mouth.

80. A community nurse saw Mrs G on 30 August and noted Mrs G reported a strange taste and dry mouth, complete food aversion and minimal dietary intake. There is no indication the nurse examined Mrs G’s mouth. On 31 August a different nurse saw Mrs G and noted she had ‘awful oral thrush’. The nurse prescribed medication. The medication appears to have resolved the thrush temporarily. When the effects returned, the Trust prescribed nystatin, which appears to have relieved the thrush during the period about which Mr E complains.

81. As noted above, NHS oral thrush guidance says the main indication of oral thrush is painful white patches in the mouth. Symptoms include an unpleasant taste and pain in the mouth, and difficulty eating and drinking. There is no standard or guidance which says whether the mouth should be examined if a patient complains of a change in taste. Change of taste is a common symptom and there is no specific guidance as there are numerous potential causes.

82. We see no indication in the clinical letter from Mrs G’s 22 August appointment Mrs G mentioned a change of taste or any other symptoms of oral thrush, and thus, we find no failing on the part of the Trust in not examining Mrs G’s mouth at this appointment.

83. The nurse who saw Mrs G on 30 August did not examine Mrs G’s mouth although Mrs G reported a strange taste, dry mouth, and inability to eat. As noted above, she did not complain of red and white patches in the mouth, which is the clear indicator of oral thrush. The next day, another nurse did examine Mrs G’s mouth, identified the oral thrush, and ordered appropriate treatment which resolved the issue. We see no indication the Trust failed to provide care in line with guidance.

84. We understand Mr E is concerned the oral thrush contributed to Mrs G’s symptoms of severe nausea and pain during August and September. Our adviser noted it is unlikely treating Mrs G’s thrush earlier would have made much of a difference to the clinical picture. Mrs G had incurable pancreatic cancer with pain and nausea. It is usually impossible to completely control these symptoms, even with a specialist palliative care team involvement. Additionally, even after the thrush was better controlled, there is no evidence her symptoms and appetite improved.

85. We see no indication of failing and we will not continue to investigate this aspect of the complaint.

1. We have carefully considered Mr E’s complaint about a GP practice in North Tyneside (the Practice) and Northumbria Healthcare NHS Foundation Trust (the Trust). We thank Mr E for bringing this complaint to us on behalf of his mother, Mrs G, who died in 2024. We understand the period surrounding Mrs G’s diagnosis with pancreatic cancer was a difficult and frightening time for both Mrs G and her family, and we are sorry they had to experience this.

2. We have reviewed Mr E’s complaint regarding the care and treatment provided to Mrs G by the Practice. We have seen no indications the Practice failed to follow relevant guidance in providing clinical care to Mrs G. While we found a failing in the Practice’s handling of Mr E’s complaint, we have seen the Practice took steps to remedy this.

3. We have also reviewed Mr E’s complaint regarding the care and treatment provided to Mrs G by the Trust when she was initially diagnosed with pancreatic cancer. We have seen no indications the Trust failed to follow relevant standards and guidance in providing care and treatment to Mrs G.