The Trust
X-ray Report
26. After his mother’s death, Mr R told us he raised complaints about the Trust. He explained a staff member invited him to a meeting. He says they told him the Trust had failed to act on an X-ray taken in August 2021. He says the X-ray had shown possible cancer.
27. The Trust said a doctor at the Trust reviewed the X-ray report on 17 August. It advised a repeat X-ray in six weeks. The doctor should have contacted Mrs F’s GP to arrange this. The doctor did not do this. The doctor and Trust have apologised. The Trust has also introduced service improvements to prevent this mistake from happening again.
28. We asked GP adviser 1 what standards apply to responding to X-ray reports. They directed us to the GMC’s, Good Medical Practice, which says, medical professionals should ‘promptly provide or arrange suitable advice, investigations or treatment where necessary.’
29. The medical records show Mrs F came to the Urgent Treatment Centre (UTC) on 30 July. The notes state an X-ray had been taken with some possible shadowing. It said that the information was not yet shared with Mrs F, and the doctor was waiting for the report.
30. On 6 August, the Trust reported on Mrs F’s chest X-ray. The report says there was a consolidation or possible bruise in the middle of the left lung. It said a follow up X-ray should be provided, after antibiotic treatment.
31. There is no further mention of this X-Ray or lung issues in the records until February 2022. On 8 February, the Trust provided a chest X-ray. It reported this on 15 February and indicated concerns for malignancy (cancer). It recommended a CT staging scan. A CT staging scan is where a CT scan is done to determine the location and progression of body cancers.
32. We found the Trust failed to meet the GMC standard. It should have promptly arranged antibiotics and a follow-up X-ray by contacting Mrs F’s GP. This failure meant the recommended care and investigations were delayed. We now need to consider whether this failing had an impact.
33. Impact
34. Mr R told us his mother may have been able to receive treatment, if the Trust acted on the X-ray report in August. He says the Trust may have shortened her life, by allowing the cancer to progress untreated.
35. In its response, the Trust said if a second X-ray was provided (as requested in August), it would have shown abnormal growth. This would have prompted a CT scan, followed by a biopsy if Mrs F was physically fit. It said chemotherapy could have been an option at that stage. However, it also noted the treatment would not have cured the cancer but might have prolonged her life.
36. Mrs F’s medical records show the Trust diagnosed her in February 2022. At that time, cancer treatments were not offered.
37. A letter from the Department of Elderly Medicine on 25 February, said that a consultant called the family and asked how Mrs F was doing. The consultant at the Trust told the family, based on their report, her condition ‘wasn’t good enough to consider further investigations as treatment options would be limited and focus would probably be on symptom care.’ The letter also said they would still refer the case for a multidisciplinary team (MDT) discussion to consider if further investigation would be beneficial.
38. The letter also said informing Mrs F of the cancer diagnosis would have harmed her mental health.
39. A GP visited Mrs F at home on 28 February. The GP notes say they had a discussion with Mrs F’s son and family. The GP noted the family had been told Mrs F had lung cancer which has spread to her liver, that she was not likely to be well enough for treatment, but an MDT would decide that soon. Within the treatment plan, it says Mrs F’s wishes had always been to die at home and avoid hospital as much of as possible unless she had an easily reversible condition.
40. A further letter on 10 March, from the Department of Elderly Medicine said the Trust were going to bring Mrs F in for a biopsy and check her treatment options. The Trust said it had spoken with a Macmillan nurse who confirmed Mrs F wanted to be home and have end of life care.
41. We asked GP Adviser 1 whether treatment would have been possible if Mrs F’s diagnosis had been made earlier. They explained that the right course of action was to provide antibiotics and after that course, arrange another X-ray. They said if the Trust had taken the correct action in August 2021, it would have provided an X-ray within six weeks. The results would have been reported around mid-September.
42. It is likely the results would have been abnormal, so the Trust would have made a two-week urgent referral for Mrs F. This means it is likely she would have been formally diagnosed by early October.
43. They said the discharge letter from Northumbria Healthcare Adult Services was useful in assessing if Mrs F was well enough for treatment. The letters said, from 6 September 2021, Mrs F was extremely agitated. She was placed under section and went into specialist mental health care until January. The Trust provided a cognitive assessment in December 2021. Mrs F scored at eight out of 30. This score is comparable to a person with very advanced dementia.
44. GP adviser 1 said Mrs F could not have had chemotherapy when agitated and cognitively impaired. Additionally, she was physically frail which meant she would be unlikely to survive chemotherapy or lung surgery. Given these circumstances, they said it would not have been feasible for her to receive cancer treatment between October and January.
45. GP adviser 1 noted Mrs F was well enough for discharge in January, but even then she required a wheelchair and help with activities of daily living. At that time, it was still highly unlikely she could have survived cancer treatment.
46. We can see that there was a five-month delay between when the Trust should have diagnosed Mrs F (October 2021) and when it did diagnose her in February 2022. However, the evidence, and advice from our GP adviser, indicate Mrs F would not have been well enough to undergo cancer treatment during that time.
47. Based on this evidence, we do not think the failure to act on the X-ray caused Mrs F to pass away earlier than expected. It is more likely than not that even if the Trust had acted sooner, Mrs F would still not have been able to have treatment in October 2021.
48. Mr R has said that the Trust were wrong to treat Mrs F under psychiatric care between September and January. He says her deterioration was likely delirium related to her fall and was temporary. He says this should have been treated medically and Mrs F should not have been treated as an inpatient.
49. We cannot comment on whether the treatment for delirium was appropriate. However, we can see that Mrs F’s cognitive score, as late as December was very low. This indicates to us that she would not have been mentally well enough to have treatment. Following this, she was physically frail. It is evident in the GP records that even while home, she required substantial support for performing activities of daily life.
50. We consider that GP 1 adviser’s view is robust, considering the evidence. We find it is not likely that Mrs F could have tolerated cancer treatment in her condition. However, as a result of Mr R’s comments, we reviewed the records again and we saw that this was not the only reason a decision was made not to treat Mrs F’s cancer.
51. The letter on 10 March shows the Trust were willing to do some further investigations to explore if treatment would be appropriate. However, the family had shared with the GP Mrs F would only want treatments for conditions which were easily reversed.
52. The Trust took this information on board and chose not to progress treatment as it would not be in line with Mrs F’s wishes. The reason the Trust did not provide further treatment was in part because of her frailty, but also because it was following the family and Mrs F’s wishes.
53. We recognise that learning Mrs F’s X-ray should have been acted on, the delays to her diagnosis, and concerns about missed cancer treatment have been very distressing for Mr R. We are sorry to hear about these upsetting circumstances and acknowledge how they added to an already difficult time.
54. The Trust has apologised for its actions and made improvements to its processes. In its complaint response on 12 February 2012, it explained to Mr R that a new system is now in place to monitor abnormal X-rays. This includes emailing all reports to the doctor, the matron of the UTC, and a nurse practitioner. The nurse practitioner acts as a safety net by flagging any urgent or ‘red flag’ reports, ensuring they are followed up by the doctor and matron.
55. We consider the actions taken by the Trust are appropriate to remedy the failing identified. For this reason, we do not believe any further action is needed from the Trust.
Amitriptyline
56. Mr R says when his mother was admitted to the Trust in December 2022, it did not provide her amitriptyline. Amitriptyline is a medication for depression. It can also be prescribed for pain relief. He believes this likely caused her to suffer pain.
57. The Trust said it provided all of Mrs F’s required medications, including amitriptyline.
58. The drugs record from 1 December shows the Trust did not give Mrs F her usual dose of amitriptyline on 5, 6, 7 and 9 December. We asked our physician adviser if this was appropriate. They explained that there could have been a valid reason for this, but it is not recorded in the notes.
59. For example, on 2 December, a pharmacist noted Mrs F was having difficulty swallowing. They suggested alternative ways to give medications, such as crushing tablets to make them easier to swallow. However, the clinical and nursing notes do not explain why amitriptyline was not given on the dates in question.
60. Since our provisional view report the Trust has provided the relevant documentation which details why staff did not give the amitriptyline. This included screen shots for the Trust’s computer system. The reasons listed were:
• 5 December 2022 – from eMeds – “patient too sleepy” • 6 December 2022 – from eMeds – “patient declined / refused” • 7 December 2022 – from eMeds – “patient declined / refused” • 9 December 2022 – from eMeds – “patient declined / refused”
61. Our physician adviser said the relevant standards for this issue is from the NMC which says nurses must, ‘keep clear and accurate records relevant to your practice,’ and GMC standards that stipulate, ‘clinical records should include…the decisions made, and actions agreed.’
62. We can see the Trust did not provide the medication however, there were valid reasons for this which were appropriately documented.
63. We also asked our physician adviser if Mrs F would have had any side effects from not being provided with her amitriptyline as usual.
64. Our physician adviser explained that amitriptyline is a neuropathic pain reliever. It works by stabilising the nerves. Its benefits build up over time. Stopping the medication for three or four days would have been unlikely to stop its effects, especially as Mrs F had been taking it for a long time.
65. We want to reassure Mr R that while Mrs F did not have her amitriptyline on some days, it is not likely this would have caused the pain to Mrs F that he was concerned about.
66. We can see the Trust acted in line with standards and therefore we have found no failings in this part of the complaint.
Morphine
67. Mr R says Mrs F was on regular doses of morphine before her admission in December 2022. He complains the Trust stopped giving her this when she was admitted, causing her pain.
68. The Trust said Mrs F was admitted for bowel obstruction. she was not in pain and therefore morphine was prescribed on an ‘as needed’ basis. as Mrs F did not experience pain during her admission, the Trust did not give her morphine.
69. We asked our physician adviser for the relevant standards on this issue and whether the Trust’s actions were appropriate. They explained the relevant standard is from the GMC which says clinicians must only ‘prescribe drugs…when you…are satisfied that the drugs or treatment serve the patient’s needs.’
70. Our physician adviser also highlighted relevant guidance from the BNF on Prescribing for the Elderly. The guidance says, ‘Elderly patients often receive multiple drugs for their multiple diseases. This greatly increases the risk of drug interactions as well as adverse reactions... The balance of benefit and harm of some medicines may be altered in the elderly. Therefore, elderly patients’ medicines should be reviewed regularly and medicines which are not of benefit should be stopped.’
71. Records show, the Trust listed Mrs F’s regular medications on admission, including 20mg of morphine twice a day. The initial treatment plan noted concerns about morphine absorption due to her bowel obstruction and recommended substituting or reducing it. Pain and observation charts for the admission period indicate Mrs F was not in pain.
72. The discharge letter states the Trust stopped morphine during the admission as it was likely contributing to constipation. It also noted Mrs F did not report being in pain.
73. Our physician adviser said opiate-based drugs should usually be stopped slowly over a few weeks. This is especially if the dose they are receiving is quite high. They said Mrs F’s dosage at 20mg was not very high. They said the most important factor to consider, was bowel obstruction and faecal vomiting, which required urgent intervention.
74. They said morphine is known to cause constipation and was likely contributing to these issues. They said bowel obstruction could quickly become a medical emergency. To avoid this escalating to a medical emergency, the Trust acted appropriately by stopping medications that increased the risk of complications, such as intestinal obstruction.
75. The Trust’s actions were in line with BNF guidance, which recommends reviewing medications on admission and stopping those causing or worsening harm. Our physician adviser said withdrawing morphine was acceptable, provided appropriate monitoring was in place.
76. The records show the Trust monitored Mrs F in the usual ward-based checks including rounding sheets and observation charts. These would have noted signs of withdrawal, such as agitation, confusion, or elevated pulse. No indications of withdrawal were recorded in the monitoring notes.
77. We have found the Trust acted in line with relevant clinical standards and there was no failing.
Discharge Medications
78. Mr R told us when the Trust discharged his mother in December 2022, it provided her with someone else’s medication. He said this caused him significant stress, as he had to urgently arrange for the correct medications.
79. The Trust apologised for the error. It explained it is working to improve its processes for managing discharge medications. This includes creating a designated area for each patient’s medications to ensure the right medicines are provided to the right person.
80. GMC standards say doctors must prescribe medications which serve the patient’s needs.
81. Our physician adviser said a patient should be sent home with the correct medications for administering at the required times. The evidence indicates the Trust did not do this. We provisionally consider this was a failure to meet the GMC standards.
Impact
82. Records show when Mr R called the Trust to report the issue, it acted quickly to resolve the problem by sending the correct medications to Mrs F via taxi. Mr R told us that this is not correct. The Trust sent a taxi to take back the wrong medications he had been given and informed him to contact 111 for new medications.
83. We consider that this issue would have delayed Mrs F having medications for a period of a few hours. However, we can also see that at the time she was not in pain (according to the hospital records). Mr R made sure he got the right medications the same evening.
84. We recognise the distress this situation caused and agree that it was wrong to discharge Mrs F without the right medications. We recognise this also could have been more serious. However, we can only make recommendations in line with actual impact caused by the events. Mr R rectified the situation by calling 111 and getting the right medications preventing Mrs F from being without medication when she needed it.
85. The Trust have apologised for its mistake and put measures in place to prevent it from happening again. It has already done what we would advise. As the Trust has already taken sufficient steps to address the issue and we do not recommend any further action on this failing.
Morphine in Discharge Medications
86. Mr R says the Trust failed to prescribe morphine for Mrs F when it discharged her. He says when he called the Trust, it said she was not in pain and did not need morphine. He requested morphine, but staff told him the pharmacy was closed. As a result, Mr R urgently sought help from district nurses who called an Out of Hours (OOH) GP. The GP prescribed morphine in the early hours of the morning.
87. Our physician adviser said the standard for this issue is the GMC standard to only prescribe medication if it meets the patients’ needs. They said the Trust did not believe Mrs F needed morphine. This is because she was not in pain during her admission and it was also likely to be contributing to her constipation. For this reason, it would not have been appropriate to prescribe her with morphine as there did not appear to be a clinical need.
88. We understand how distressing it must have been for Mr R when he thought Mrs F might suffer with pain. We appreciate that no one wants their loved ones to suffer. Mr R would not have been aware that Mrs F’s pain had been monitored and that there were valid clinical reasons not to prescribe morphine. We understand his concern when he was informed that morphine was not provided and that it was not needed at the time of discharge.
89. Records show the Trust reviewed Mrs F’s medication. It recognised how morphine may have been affecting her constipation issues and made a plan to provide morphine if needed and review her pain levels. We have found the Trust acted appropriately and met the GMC standards. We have found no failing here.
The Practice
GP Home Visits
90. Mr R complains the Practice should have been providing his mother with home visits on a two-weekly basis. He says this was agreed as part of her palliative care plan. He says despite this, Practice staff did not visit Mrs F for three months, until her sad death in July.
91. The Practice said an MDT happened in May 2023. It explained that decided Mrs F was stable and monthly visits would be provided, if needed. It said there were multiple interactions between the family and the Practice between May and July and no home visits were deemed necessary. Where a physical interaction was needed, the Practice arranged for district nursing to undertake those actions.
92. The medical records show after the Trust diagnosed Mrs F with lung cancer, the Practice made a referral to palliative care. On 2 March the Practice wrote an EHCP. On 3 August 2022, a GP noted Mrs F should receive palliative care input. They said she was currently stable and after a meeting it had agreed to review her monthly.
93. The last home visit was on 24 April 2023. On 24 May the records state a palliative care meeting was held with GPs, Macmillan nurses and others. The notes state Mrs F was stable.
94. We can see between May and July 2023, the GP Practice acted in the following ways, on the following dates: • 16 May & 17 May Communication with nursing regarding management of constipation • 9 June Call with nursing • 14 June Advice provided to family regarding urine infection • 16 June Phone call with family regarding antibiotics • 21 June GP response to Mr R’s query about home visits • 28 June Phone call with family regarding neck rash
95. We asked GP adviser 2 for the relevant standards. They directed us to NICE guidance NG142. It says practitioners should ‘repeat assessments of [patient’s] holistic needs and reviews of their advance care plan when needed.’
96. They also directed us to NHSE’s ‘Delivery plan for recovering access to primary care’. They explained at the time, GP Practices were operating under the ‘Modern General Practice model’. As outlined in the delivery plan, GPs were newly empowered to use telephone or face-to-face appointments and were able signpost patients to self-care or local services.
97. The guidance says the new model will aid practices to ‘better assess [patients] need and tell them on the day how their request will be handled, based on clinical need.’ It says ‘patients can be directed to the most appropriate practice staff member for assessment and response, without first being seen by a GP.’
98. GP adviser 2 explained that this new approach allowed GPs to triage care to another health professional, if appropriate.
99. We asked GP adviser 2 if it was appropriate for the Practice to review the August 2022 care plan and provide reviews ‘as needed’. GP adviser 2 explained that it was appropriate to regularly review a patient’s needs and update their care plan. This is set out in the NG142.
100. They said there was no criteria about how often a GP should see a patient face-to-face when they are in end-of-life. They said visits should be provided if there is a specific clinical need for them to be seen by a GP. They said as Mrs F was stable at the time of the MDT, it was appropriate to assign a review on an ‘as needed’ basis.
101. They said if Mrs F presented with an illness which meant a home visit was needed, the GP should then visit or delegate the care, as allowed under the General Practice model.
102. We could see the GP Practice provided many assessments over the telephone and was able to prescribe relevant medications between May and July. There was indication a home-visit was needed when Mrs F developed a neck rash. When this happened, the GP arranged a nurse to attend the home and assess the rash.
103. We can see it was appropriate for the Practice to review the plan for home visits. This was in line with NG142. In addition, we could see no evidence that Mrs F required face-to-face input from a GP. When she needed a physical assessment, the Practice delegated the care effectively, to a nurse. This was in line with NHSE’s General Practice model. Our view is that the Practice acted in line with relevant standards and we have not found a failing.
104. We recognise it felt to Mr R that the Practice were not fulfilling its agreement to review Mrs F regularly. We also recognise there is no clear documentation in the records that the change in plan from May was clearly shared with the family. This may be why there was some understandable frustration from Mr R. However, we hope Mr R can be reassured that Mrs F’s ailments were effectively monitored and treated by the Practice and district nursing team.
Do Not Attempt Resuscitation (DNAR) Documentation 105. Mr R says on the day his mother passed away, there was no in-date DNAR for her. As a result, paramedics who attended said they might have to attempt resuscitation on Mrs F. He said this was extremely distressing given his mother’s frailty and the potential for causing her pain.
106. The Practice said there was an in-date DNAR in place at the time of Mrs F’s sad death. It said that on 1 July, a nurse noted that the DNAR document in the house was out of date. They intended to get the in-date version as they could see a GP had recorded that DNAR was in date.
107. Later in the day, a nurse noted an in-date DNAR had been located. The Practice stated it was likely there were two paper versions of the DNAR in the house and the out-of-date one was found first, but the correct one was located afterwards.
108. GP adviser 2 explained that the relevant standard for this comes from NICE Guidance NG142, which states that ‘health …practitioners providing end of life care coordination should…ensure that regular …reviews of…advance care plans are offered.’ This means GPs involved in end-of-life care should routinely review decisions about resuscitation and ensure a valid DNAR is in place if resuscitation is not appropriate.
109. DNARs are documented by a GP in a patient’s notes. If a DNAR is nearing its expiry date, most GP systems include an alert to prompt a review and update if needed.
110. Medical records show that when Mrs F was discharged from hospital in December 2022, she had a DNAR form. The Practice was notified and this recorded on its system. In April 2023, a GP checked the DNAR and noted that it was in date. A DNAR is in effect for a year from the date it was issued. This means that the DNAR from December 2022 was relevant until December 2023.
111. It is worth noted that a DNAR isn’t only a document, it is a decision which is recorded on electronic systems. So when the GP checked the DNAR was in date on their system, it was still valid. There was a valid DNAR in place for Mrs F until December 2023. The issue was locating a document of this, because Mrs F was at home and the incident occurred on the weekend when a GP could not be reached.
112. Ambulance records show that paramedics saw an in-date DNAR and provided a photo (this is not legible on the document provided). Nursing notes after the paramedic visit state that Mr R told the nurses the DNAR was out of date. However, the nurses checked and confirmed it was valid.
113. Mr R says there was not an in-date DNAR at home. He says that the document from December 2021 was never given to him. This is because the Trust provided another patients medication and information (see above). He also said the in-date DNAR was one written by the OOH GP who came after the paramedics.
114. It is not possible for us to exactly determine whether the in-date DNAR noted in the records was from the Trust or a new one provided by the OOH GP.
115. However, the GP’s responsibility was to ensure there was an active DNAR in place. As mentioned previously this relates to a registered decision and not the piece of paper. A GP confirmed there was one during a review in April 2023 and it did not need to be reviewed until December 2023.
116. The issue seems to have been locating the paper version during a distressing moment. It may be that there were two paper copies of the DNAR in the home, one that was out-of-date and another that was valid. Or the OOH GP wrote a new one for Mrs F.
117. While we cannot determine exactly what happened (accounts by Mr R, the Practice, Nursing and Paramedics, do not match) we can see that either an in-date one was located, or the OOH GP wrote a new one. Either way, this created a short period of distress while an in-date document of the DNAR was not in the family’s possession. We are sorry to hear how that affected the family.
118. We can see the GP fulfilled its responsibility to check there was a valid DNAR in place. The decision itself was in place until December. GP adviser 2 explained that it was not the GP’s responsibility to check the DNAR paperwork in the family home. This is typically the responsibility of district nurses.
119. The GP’s responsibility was to ensure there was an active DNAR in place, and this was confirmed during a review in April 2023. We find the Practice acted in line with the relevant standard and there was no failing here.
End-of-Life Medication
120. Mr R says on the day his mother died, she did not have the required end-of-life medications available. He says those which were at the home, were out of date and could not be used. He says this left his mother feeling ‘tortured’ as she was without the medication she needed to pass peacefully.
121. The Practice said there were in-date medications at the home apart from four vials of cyclizine. Cyclizine is a medication which treats nausea and sickness. The Practice said the records were unclear as notes at 7.45am said the cyclizine was out of date and the family needed to call 111 for a new prescription.
122. But at 12.15pm nursing notes state medications were checked, all were in date except four vials of cyclizine. One vial of cyclizine was in date. There was also one new pack of cyclizine medications.
123. GP adviser 2 said the relevant standards are from NICE’s ‘Palliative care – general issues.’ This says professionals involved in palliative care, such as GPs, district nurses, and palliative care nurses, should manage anticipatory prescribing.
124. On 1 July at 7.31am, the family called district nurses and said Mrs F had been sick and was unwell. The family confirmed there were medications in the home. Nurses planned to do a home visit.
125. When nurses arrived at 7.45am, they could not find the end-of-life prescription. They saw the cyclizine was out of date. The nurses advised the family to call 111 for an assessment, a new prescription and in-date cyclizine.
126. The family called for an ambulance at approximately 9.20am. An ambulance arrived at 9.27am. At 10.01am, there is a record of a call to 111 about obtaining a new cyclizine prescription. A clinician arranged for an OOH GP to visit.
127. The ambulance notes say the GP arrived rapidly and prescribed injectable medications.
128. The OOH GP visited at 10.30am. They provided midazolam and cyclizine. They prescribed additional medications and contacted district nurses to arrange an urgent visit.
129. District nurses returned at 12.15pm. Notes say Mr R told nurses the OOH GP had started the end-of-life medications. He also said all anticipatory medications were out of date and he would be going to the pharmacy immediately.
130. The nurses checked the medications and found all were in date, except for four vials of cyclizine. One vial of cyclizine was in date, alongside a new pack of the medication issued that day. They took photos of the medications, which we have reviewed.
131. The photos show four vials of cyclizine were out of date. One vial was in date, expiring in September 2024. A new box of cyclizine had already been issued that day.
132. We asked GP adviser 2 if four out of date vials of cyclizine, meant the Practice had failed to meet standards.
133. They said anticipatory medications in the home are usually checked by nursing staff. The GP relies on the information given to them by nursing and palliative care staff, as the palliative care team works collaboratively (including GPs, nurses, and palliative care staff) to meet patients’ needs. GPs depend on the information available to them at the time.
134. Records show the GP prescribed anticipatory medications in April 2022. During a home visit in April 2023, the GP asked about the medications. The family said they had them and would ensure they were located. Nurses had previously checked with the family in April and May that the medications were in the home. A nurse noted they were there in April but did not specify whether they were in date.
135. The evidence indicates there was one in-date vial of cyclizine in the home, alongside a new box issued that day. Records also confirm all other needed medications were present. Nursing notes before and after the GP’s visit support this. Therefore, we cannot see evidence that Mrs F lacked the medications she needed.
136. We find the Practice acted appropriately and in line with NICE guidance to ensure Mrs F was prescribed anticipatory medications. We recognise there was some confusion about whether in-date cyclizine was available, but evidence suggests it was, although the family may not have located it immediately.
137. We understand the final moments of a loved one’s life can be very distressing. It is clear Mr R and the family acted with Mrs F’s best interests at heart, wanting her to receive the medications she needed to pass peacefully.
138. We appreciate that even brief worry about medication availability would be upsetting. We are sorry that confusion about medication availability must have added to the family’s distress.
139. Based on the evidence, we find no failing here. Although there was confusion, the evidence indicates necessary medications were available.
140. In summary, we do not uphold Mr R’s complaint. We found issues with reporting of an X-ray. However, we do not believe the failing led to Mrs F’s life being shortened. We also think the Trust have taken the right actions to put the failing right. We also found issues with the Trust discharging Mrs F without her medications. We think the Trust have taken the right action to rectify this failing.
141. We thank Mr R for bringing his complaint to us and giving us the opportunity to independently investigate the issues in his complaint. As a result of this complaint, the Trust has already made improvements to its service delivery. It is due to people like Mr R raising concerns that issues can be improved and resolved. We appreciate the time he has taken to address his concerns with the Trust, the Practice and the Ombudsman and we wish him all the best.