Palliative care data gaps

Lack of a specified palliative and end-of-life care data set, hindering integrated care boards from understanding population needs.

166 items 10 sources 3 inquiries
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Where this theme appears

Palliative care data gaps has been flagged across 10 independent accountability sources:

3 inquiry recs 3 PFD reports 81 committee recs 4 CQC actions 5 PPO recs 1 IMB report 11 IMB recs 2 detention investigation recs 50 PHSO decisions 6 LGO/SPSO decisions

When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.

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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.

R71 — National CDI death monitoring
Vale of Leven Inquiry
Recommendation: Scottish Government should identify a national agency to undertake routine national monitoring of deaths related to CDI.
Gov response: Section 2.1 notes the report's call for better national monitoring of HAI-related mortality, particularly C. diff deaths (recommendations 70 and 71). While the response details national and local surveillance data collection for HAI policy and …
Accepted
38 — Improve perinatal mortality recording
Morecambe Bay Investigation
Recommendation: Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units …
Gov response: 103. We accept this recommendation. We will explore the feasibility of publishing data about the safety and quality of maternity services at individual Trust level. 104. As recommended by the Morecambe Bay Report, MBRRACE-UK has …
Accepted
IR2-5 — Classification of Infections and Severity
Infected Blood Inquiry
Recommendation: I recommend that infections eligible for compensation should be classified in the following manner: a) there should be defined categories for each type of eligible infection, and the stages through which it progresses, and for each category defined degrees of …
Gov response: The Government recognises the different levels of suffering from different infections and degrees of severity. Therefore, compensation will be available for all of the categories of loss recommended by the Inquiry - these are referred …
Accepted
#12 —
Public Accounts Committee
Recommendation: The Department and NHS England told us that data on patient-level activity from hospices, which ICBs need in their role as commissioners, is not strong or robust enough, because hospices are only obliged to report activity data when they are …
Response Pending
#12 —
Health and Social Care Committee
Recommendation: We urge the department to mandate ICBs to maintain a fully populated palliative and end of life care dashboard that is actively used for commissioning, service planning, quality improvement, and inequality monitoring across their local system. (Recommendation, Paragraph 52)
Response Pending
#11 —
Health and Social Care Committee
Recommendation: National palliative and end of life care data provide valuable insight into patterns of healthcare use and location of death, however the evidence presented demonstrates substantial gaps in local data collection and utilisation. Without consistent, granular and timely data, ICBs …
Response Pending
#27 — Departmental annual report shows significant omissions on preventative and end-of-life care.
Public Accounts Committee
Recommendation: The NHS Long Term Plan states that ill health prevention helps the public to stay healthy, as well as moderating demands on the NHS. The Department recognised in its 2023–24 Annual Report that there “is still much work to do …
Gov response: 2.1 The government agrees with the Committee’s recommendations. Target implementation date: September 2025 2.2 The department is committed to the continuous improvement of its Annual Report and Accounts (ARA) to ensure the content is as …
Accepted
#25 —
Public Accounts Committee
Recommendation: The NAO report describes how independent hospices offer additional services that are typically outside the remit of the NHS, for example certain complementary therapies, funded from hospices’ charitable donations. Hospices offer support to the family, friends and carers of those …
Response Pending
#22 —
Public Accounts Committee
Recommendation: Some hospices have recently reduced the volume or range of services they provide and others are planning to do so, at a time when demand for palliative and end-of-life care is rising.45 Hospice UK told us that hospices are facing …
Response Pending
#19 —
Public Accounts Committee
Recommendation: Professor Murtagh told us that for a long time it has been known that around one in four adults who need palliative care do not get it, and that recent research suggests that the proportion may now be even higher.36 …
Response Pending
#17 —
Public Accounts Committee
Recommendation: Professor Murtagh stressed that ICBs need to commission on the basis of activity and outcomes. Professor Murtagh explained that this approach is already used elsewhere in the NHS through a blended payment model that aligns payments with incentives, and questioned …
Response Pending
#9 —
Public Accounts Committee
Recommendation: NHS England told us that although it does collect patient-level activity data, it needs to start collecting more. It currently does not collect activity data from all hospices and therefore cannot determine how much care ICBs are buying from hospices, …
Response Pending
#1 —
Public Accounts Committee
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health and Social Care (the Department) and NHS England on the provision of palliative and end-of-life care, and the funding of …
Gov response: The government agrees with the committee’s recommendation: service specifications for adults and children and young people, outlining expectations of what palliative care and end-of-life care services are commissioned. This is further supported by NHS England’s …
Accepted
#5 —
Public Accounts Committee
Recommendation: The Department and NHS England are not responding to the growing financial crisis in the adult hospice sector with the seriousness and urgency needed. The independent hospice sector is facing a serious financial situation that is already affecting patient care. …
Gov response: The government agrees with the Committee’s recommendation: stability of hospices in their footprint, and the steps being taken to mitigate risks. ICBs are already expected to understand current and projected utilisation, costs, and risks across …
Partially Accepted
#4 —
Public Accounts Committee
Recommendation: Too many patients spend their last days receiving palliative care in acute hospitals, which does not always achieve the best outcomes for patients nor represent value for money. Patients are frequently receiving palliative care and reaching the end of their …
Gov response: The government agrees with the Committee’s recommendation. community, to ensure patients and their families receive personalised care in the most appropriate setting, and palliative care and end-of-life care services, including hospices, will have a big …
Accepted
#2 —
Public Accounts Committee
Recommendation: Only now are the Department and NHS England developing a Modern Service Framework for palliative and end-of-life care, but so far the details are unclear. There has not been a new national strategy for improving palliative and end-of-life care in …
Gov response: The government disagrees with the Committee’s recommendation. Whilst the government agrees that DHSC and NHS England should work with, and take on board, the views of the hospice sector as part of the development of …
Not Accepted
#22 —
Health and Social Care Committee
Recommendation: We recommend that the Government moves towards sustainable and predictable models of funding for hospices, financing their running as well as investment costs, which reflects the increasingly central role they will play in delivering end of life care. This funding …
Response Pending
#20 —
Health and Social Care Committee
Recommendation: The Government must hold ICBs to account for delivering bereavement services. This does not need to wait for the forthcoming Modern Service Framework as there are already clearly defined expectations for what ICBs should deliver in this area. In its …
Response Pending
#19 —
Health and Social Care Committee
Recommendation: Bereavement, and pre-bereavement support are essential, yet access remains patchy, poorly commissioned, and often difficult to navigate. Despite its inclusion in the current Ambition Framework, significant gaps persist, particularly for culturally diverse communities and children and young people. (Conclusion, Paragraph …
Response Pending
#18 —
Health and Social Care Committee
Recommendation: The Government need to publish an evidence-based plan, supported by up-to-date workforce modelling, setting out how it will increase the capacity and sustainability of all sectors of the specialist palliative and end of life care workforce, as part of the …
Response Pending
#17 —
Health and Social Care Committee
Recommendation: Current shortages in the specialist workforce are putting palliative care services in an unsustainable position which threatens their ability to deliver equitable and high-quality palliative and end of life care. Extensive consultant vacancies, impending retirements, limited training places and widespread …
Response Pending
#16 —
Health and Social Care Committee
Recommendation: We recommend that end of life care be included as a core skill for the generalist health and social care workforce, with a clear and defined set of competencies required to deliver high-quality and person-centred palliative and end of life …
Response Pending
#10 —
Health and Social Care Committee
Recommendation: We recommend that the Department implement the 90% target for the percentage of individuals in the last year of life documented on the Palliative Care Register and that it reports annually on progress against this target to monitor the impact …
Response Pending
#9 —
Health and Social Care Committee
Recommendation: We support increasing use of the Palliative Care Register for early identification of individuals, including children and young people with PEoLC needs. However, we are concerned that its use is likely to decrease given the removal of funding incentives for …
Response Pending
#7 —
Health and Social Care Committee
Recommendation: We recommend that the MSF includes specific guidelines and requirements for ICBs to enable access to 24/7 PEoLC services, including access to symptomatic medication, and in-person care where necessary. We call on the Government to provide an assessment of both …
Response Pending
#6 —
Health and Social Care Committee
Recommendation: It is unacceptable that access to 24/7 palliative and end of life care services remains patchy throughout England. Individuals nearing the end of life should be able to access the right care, advice and medication, wherever they are and regardless …
Response Pending
#5 —
Health and Social Care Committee
Recommendation: We are concerned that the Minister was unable to commit to providing clear and specific standards and guidance for babies, children and young people’s palliative and end of life care in the Modern Service Framework (MSF). We strongly recommend that …
Response Pending
#53 — Record detailed post-16 pathway and long-term outcome data for care-experienced individuals.
Education Committee
Recommendation: The Department must record data on post-16 pathways and attainment for those with care experience—including detailed data on qualifications, course types and completion rates. The Department should also monitor long-term outcomes—employment quality, income levels, and 100 higher education progression for …
Gov response: PLANS ALREADY IN PLACE The Get Britain Working White Paper announced the Youth Guarantee for 18–21-year-olds in England to ensure young people are either learning and earning. This includes access to high-quality training, apprenticeships, and …
Not Addressed
#6 — Skills England faces challenges with data collection, levy system, and programme communication.
Education Committee
Recommendation: Skills England has been broadly welcomed by the further education and skills sectors. We agree with the Government’s priorities for Skills England, including identifying national and local skills needs, simplifying access to training, and collaborating with employers and training providers …
Gov response: ACCEPT Skills England recognises the need to strengthen and expand jobs and skills data across government to enable robust skills needs assessments, particularly at local levels. High-quality data is also essential for delivering the Industrial …
Partially Accepted
#11 — Gather annual transport manufacturer data on vocational training effectiveness; report findings to DfE, DWP.
Transport Committee
Recommendation: The Department for Transport should on at least an annual basis gather information from British transport manufacturers on how effectively the UK’s vocational training system is delivering a robust pipeline of skills, and report these findings to the Departments for …
Gov response: Through its engagement with industry, Skills England is in continuous dialogue with employers, including those in the transport manufacturing sector, about what they need from the vocational skills system. The Department for Transport will engage …
No Published Response
#7 — Collect and publish intersectional data on victims of religiously and racially aggravated hate crimes.
Women and Equalities Committee
Recommendation: The Government should collect and publish data on the religion, ethnicity and sex of victims of both religiously and racially aggravated hate crimes to help policymakers understand the extent of anti-Muslim hate crimes and the role gender plays in such …
Gov response: 27. The Committee asked that Government ensure police officers are appropriately trained to effectively deal with hate crimes targeted at Muslim women. The Government recognises the importance of ensuring officers are appropriately trained to recognise, …
No Published Response
#26 —
Public Accounts Committee
Recommendation: Baroness Finlay emphasised the role that hospices have as an important source of expertise in palliative and end-of-life care, available to professionals in the NHS such as district nurses and care assistants.58 NHS England told us how hospices support training …
Response Pending
#24 —
Public Accounts Committee
Recommendation: NHS England agreed that the hospice sector is fundamentally in financial distress and that there is a need to move quickly to resolve and fix the problems. But it stressed the need to avoid perpetuating problems, such as supporting a …
Response Pending
#23 —
Public Accounts Committee
Recommendation: NHS England emphasised that it is aware that every hospice provider is worried about financial sustainability, but that it is unaware of any hospices facing immediate closure.50 It told us it expects ICBs to undertake quality impact assessments if a …
Response Pending
#21 —
Public Accounts Committee
Recommendation: Professor Murtagh stressed the importance of having earlier conversations with patients and their families about possible deterioration and approaching death, to ascertain their wishes. Without such conversations, patients may continue to have high-cost treatment they may not benefit from.43 NHS …
Response Pending
#20 —
Public Accounts Committee
Recommendation: The Department and NHS England agreed that there are gaps in provision of palliative and end of life care and that it must meet demand where it is needed.39 They also acknowledged the importance of moving care away from costly …
Response Pending
#16 —
Public Accounts Committee
Recommendation: NHS England told us that ICBs are required to understand the needs of their populations and their projections of future demand.30 NHS England acknowledged that it must take the lead on establishing a single commissioning approach for the provision of …
Response Pending
#15 —
Public Accounts Committee
Recommendation: ICBs currently fund hospices largely through grants and block contracts, which do not provide clarity over what is being purchased.28 The Department and NHS England acknowledged that there must be a move away from funding hospices in this way towards …
Response Pending
#13 —
Public Accounts Committee
Recommendation: The Department and NHS England told us about the ‘Modern Service Framework’ they are currently developing, which they intend will bring together disparate elements of the system and will set out what “good” commissioning for palliative and end-of-life care looks …
Response Pending
#10 —
Public Accounts Committee
Recommendation: There has not been a renewal of the government’s approach to delivering and improving palliative and end-of-life care in England since the first national strategy was published in 2008. The Health and Care Act 2022 introduced a legal duty for …
Response Pending
#6 —
Public Accounts Committee
Recommendation: The NHS is at risk of losing the huge value it gains from independent hospices beyond the provision of statutory palliative and end-of-life care. Independent hospices provide enhanced care compared with the NHS, such as complementary therapies, funded from charitable …
Gov response: The government disagrees with the Committee’s recommendation. The government and NHS England are working closely with Hospice UK, Marie Curie, Sue Ryder and Together for Short Lives to ensure the views of hospices are gathered …
Not Accepted
#3 —
Public Accounts Committee
Recommendation: NHS England has been too slow to enforce a commissioning approach for the provision of palliative care that focuses on the quality of outcomes for patients. ICBs continue to fund hospices largely through grants and block contracts, despite the NHS …
Gov response: The government agrees with the Committee’s recommendation. ICBs to respond effectively to current and future needs of their population, in line with the wider expectation of the Model ICB Blueprint. More specifically, NHS England has …
Accepted
#21 —
Health and Social Care Committee
Recommendation: Hospices form an integral part of palliative and end of life care provision at home and in the community and we welcome the fact that the Government intends for them to play a bigger role as part of its shift …
Response Pending
#13 —
Health and Social Care Committee
Recommendation: Poor data sharing and lack of integration across NHS, social care, voluntary and private providers creates confusion, delays and gaps in continuity for people at the end of life, frequently placing the burden of coordination care on patients and carers …
Response Pending
#8 —
Health and Social Care Committee
Recommendation: The role of social care in the provision of palliative and end of life care has been overlooked for far too long, and we are concerned that the Government’s plans to remove local authorities from ICBs will only make the …
Response Pending
#4 —
Health and Social Care Committee
Recommendation: If the Modern Service Framework is to deliver meaningful change it must be more than a well-intentioned ambition. ICBs and the Department need to be held accountable for meeting the Framework, with clear consequences if its standards are not met. …
Response Pending
#3 —
Health and Social Care Committee
Recommendation: We are unclear about what is fundamentally different about this framework compared to existing documents, such as the Ambitions Framework and the NHS National Standards for Palliative and End of Life Care. In particular, what different approach it will take …
Response Pending
#2 —
Health and Social Care Committee
Recommendation: We welcome the Government’s plans to introduce a Modern Service Framework to set national standards for palliative and end of life care services, and the Department’s commitment to co-produce this work alongside key stakeholders. However, we approach this with a …
Response Pending
#51 — Care leavers face significant challenges transitioning into further education, employment or training.
Education Committee
Recommendation: Care leavers face significant challenges transitioning into further education, employment or training. Care leavers aged 19–21 are three times more likely not to be in education, employment or training than their peers. There is insufficient support for those transitioning into …
Gov response: PLANS ALREADY IN PLACE The Get Britain Working White Paper announced the Youth Guarantee for 18–21-year-olds in England to ensure young people are either learning and earning. This includes access to high-quality training, apprenticeships, and …
Accepted
#14 — Develop an evidence-led plan to increase diversity within the transport manufacturing sector.
Transport Committee
Recommendation: Skills England should by the end of 2026 set out an evidence-led plan, commissioning research necessary to fill gaps in knowledge on what has worked best in the manufacturing sector, detailing how it will support the Government’s target to increase …
Gov response: The Government is committed to breaking down barriers to opportunity by building skills for opportunity and growth so that every young person can follow the path that is right for them. DfT is delivering against …
No Published Response
#23 — Home Office monitors police efficiency program progress, while College seeks measurement consistency.
Public Accounts Committee
Recommendation: We asked whether the Home Office had the data needed to monitor progress towards its planned savings of £354 million by 2028–29.58 The Home Office said it is important to get the right data to hold police 51 Qq 75-77, …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 The Police Efficiency and Collaboration Programme (PECP) has an annual cashable efficiencies target of £354 million by 2028-29 and a non-cashable efficiencies target of …
Response Pending
#14 — Integrated Care Boards need better population data to understand and support service provision.
Health and Social Care Committee
Recommendation: As identified in the report of the HSIB (now the Health Services Safety Investigations Body (HSSIB)) on variations in palliative care services to adults, we agree that better data on the population within an ICB catchment area needs to be …
Gov response: While the NHS has always been required to commission appropriate palliative and end-of-life care services to meet the reasonable needs of local populations, palliative care services were added to the list of services an integrated …
Accepted
#13 —
Science, Innovation and Technology Committee
Recommendation: The public has shown a strong appetite for more information. The Government should attempt to quantify the four forms of health impacts identified by Professor Whitty. Further, it should consider whether it is possible to provide an analysis of—either consistently …
Gov response: GO-Science and the GCSA are committed to ensuring science advice provided to Ministers and officials is relevant and fit-for-purpose. The nature and demands of the pandemic, including the spotlight on SAGE, has required action to …
Under Consideration
The Verne (2024)
The Minister to consider establishing an end-of-life care facility at HMP The Verne.
Other
Altcourse (2020)
Altcourse is seeing, as are other prisons, an increase in its age profile. Many older prisoners require more age-appropriate accommodation, enhanced or more specialised healthcare provision, and in some cases end-of-life care and palliative care. The prison developed an excellent older person’s strategy, but this could only be partially implemented owing to finite finance and lack of an overarching national …
Ministry of Justice
Rye Hill (2022)
The difficulties surrounding appropriate arrangements for end-of-life care and compassionate release, imposed by current HMPPS facilities and procedures, impact HMP Rye Hill disproportionately because of the higher than average age profile of the prisoners held. The current procedures do not seem to facilitate humane treatment of these prisoners.
HMPPS
Usk and Prescoed (2025)
HMPPS should consider specific measures to address the increased demand for general and palliative healthcare, additional resources and funding (e.g., expanded weekend services, more staff for hospital escorts), and the unsuitability of HMP Usk's current infrastructure for older individuals, ensuring plans meet complex needs in the medium to long term.
HMPPS
North Sea Camp (2020)
Address the need for an end of life care suite at HMP North Sea Camp.
HMPPS
Bure (2020)
Will consideration be given to providing special accommodation and resources for palliative care at HMP Bure, and developing further cells to provide better conditions for the disabled?
HMPPS
Rye Hill (2023)
The Board is still concerned that not one compassionate release has been agreed despite a number of applications and despite the increase in the number of terminally ill prisoners dying in custody at Rye Hill.
HMPPS
Rye Hill (2024)
The Board was pleased that one terminally ill prisoner was given compassionate release during the reporting period. However, the Board is still concerned that the process remains unnecessarily difficult, particularly as it requires a GP’s diagnosis of terminal illness to be confirmed by a hospital consultant. The long waiting times to see an NHS consultant add unnecessary delays, which can …
HMPPS
Long Lartin (2024)
Healthcare centre (HCC): what full programme of measures is planned to provide all necessary facilities (including end of life) for in-patients?
HMPPS
Lancaster Farms (2020)
There is a lack of wheelchairs to support prisoners with reduced mobility accessing health care and other amenities. Certain cases have illustrated difficulties of working with external agencies for the support and potential release of those with palliative care needs (see paragraphs 8.5 and 8.9).
Governor / Director
Cardiff (2023)
The last health needs analysis in HMP Cardiff took place in 2017. Will the Health Board now address this issue urgently?
NHS / Healthcare Provider
P-001867 — The Princess Alexandra Hospital NHS Trust
Mrs E complains about the Trust's palliative care and treatment of her son in April 2021. She complains about its communication, pain management and how available its doctors were.
NHS in England Mar 2023
P-003498 — A practice in the Suffolk area
Mrs R complains the Practice did not appropriately manage her husband’s palliative care. She says it did not properly manage his pain relief and delayed referring him to a hospice.
NHS in England Apr 2025
P-003663 — East Kent Hospitals University NHS Foundation Trust
Mrs M complains about how clinicians at two of the Trust’s hospitals treated her husband for pancreatic cancer towards the end of his life.
NHS in England Upheld Jul 2025
P-001182 — Imperial College Healthcare NHS Trust
Mr O complained about the Trust’s care and treatment provided to his partner, Miss I, for kidney stones. Mr O also complained about the Trust’s decision to start palliative care and the care that was provided.
NHS in England Upheld Nov 2021
P-001635 — A medical practice in the Havering area
Mrs E complains the Practice did not add her husband to its palliative care register in September 2020 meaning he did not get the needed pain management, oxygen, steroids, and palliative care visits that he should have.
NHS in England Oct 2022
P-001894 — Manchester University NHS Foundation Trust
Ms R complains the Trust failed to manage her mother’s pain medication in the days leading up to her death. She also says the Trust’s poor communication led to her feeling confused about her mother’s care.
NHS in England Mar 2023
P-002256 — University Hospitals Birmingham NHS Foundation Trust
Mr R complains about how the Trust cared for his father. He says it did not give him support, provide palliative care or give him dignity at the end of his life.
NHS in England Oct 2023
P-002593 — Croydon Health Services NHS Trust
Miss A complains the Trust did not tell her or her mother that her mother's cancer had spread and she had a short time to live. She also complains about the end of life care.
NHS in England Partly Upheld May 2024
P-002913 — An independent provider in the Hull area
Miss M complains about the end of life care and treatment given to her mother.
NHS in England Partly Upheld Sep 2024
P-003424 — A practice in the Walsall area
Miss R complains the Practice did not take appropriate action to investigate her late sister’s symptoms when she had bladder cancer and prescribed antibiotics that did not help. Miss R also complains the Trust failed to diagnose her late sister’s bladder cancer, did not investigate her symptoms properly, provided no …
NHS in England Partly Upheld Mar 2025
P-003478 — Midlands Partnership University NHS Foundation Trust
Ms A complains about the care provided to her mother in November and December 2022. She complains about the decision to put her mother on end-of-life care, the medication given, not getting input from the Parkinsons team and poor communication with the family.
NHS in England Apr 2025
P-003681 — University Hospitals Sussex NHS Foundation Trust
Miss Q complains staff did not provide her father with sufficient palliative pain relief in March 2023 when he was approaching the end of his life.
NHS in England Partly Upheld Jul 2025
P-004371 — Lewisham and Greenwich NHS Trust
Mrs E complains about the care the Trust provided her father between March and April 2022. She says it delayed scanning to identify his cancer had spread, delayed moving him to palliative care and discharging him, asked her and her brother to take a COVID-19 test and falsely claimed to …
NHS in England Nov 2025
P-004404 — Warrington and Halton Hospitals NHS Foundation Trust
Dr D complains the Trust ignored her father's pain levels, denied him appropriate pain management and did not make a timely referral to the palliative care team.
NHS in England Dec 2025
P-004533 — Central London Community Healthcare NHS Trust
Mrs H complains about the care the Trust provided to her husband, Mr H on 24 July 2024. Specifically, she complains 1) the Trust’s official palliative care mobile phone was either switched off or left unanswered rendering Mrs H unable to get help and seek emergency end-of-life support for Mr …
NHS in England Dec 2025
P-001312 — A care provider in the Leeds area
Mr N complained about the quality of palliative care and wound management the care provider gave to his cousin, Mr O, who was a nonverbal communicator.
NHS in England Feb 2022
P-001411 — A medical practice in the Hampshire area
Mrs E and Mrs S have raised concerns about the care and treatment their late mother, Mrs N, received from a Hospice and a medical practice in Hampshire between June 2018 and 12 January 2019.
NHS in England Upheld Jun 2022
P-001504 — A medical practice in the Luton area
Mrs O complains about failings in GP care provided to her mother as she neared the end of her life.
NHS in England Aug 2022
P-002653 — Gateshead Health NHS Foundation Trust
Mr E complains about the care the Trust provided to his mother from 7 to 24 February 2018. Mr E says the Trust put his mother on end-of-life care and treated her with excessive and inappropriate sedative medication.
NHS in England May 2024
P-002719 — The Hillingdon Hospitals NHS Foundation Trust
Mrs C complains Mr R’s pain was not managed or monitored appropriately and he missed regular doses of prescribed pain relief, which he took regularly before his admission. She also says he was given an inappropriate dose of oramorph and the family were not told when he was reaching the …
NHS in England Upheld Jun 2024
P-002824 — University Hospitals Birmingham NHS Foundation Trust
Mrs G complained about the care the Trust provided to her mother during her final admission. She was also unhappy about its communication regarding how close she was to the end of her life.
NHS in England Jul 2024
P-003367 — County Durham and Darlington NHS Foundation Trust
Mr O complains the Trust did not properly manage his late father-in-law’s pain, pressure sores or stroke.
NHS in England Upheld Mar 2025
P-003491 — South Tyneside and Sunderland NHS Foundation Trust
Mrs A complains the Trust ignored her husband’s wish to be re-intubated and excluded her from any discussion about this. She also complains his treatment was delayed and she was not told when the palliative care team became involved.
NHS in England Apr 2025
P-003702 — Ashford and St Peter's Hospitals NHS Foundation Trust
Mrs B complains about the Trust’s management of her husband's diagnosis and decisions around palliative care.
NHS in England Partly Upheld Jul 2025
P-003643 — University Hospitals of Derby and Burton NHS Foundation …
Mr B, and his family, complain about the care provided to his father, Mr C, by the Trust from 6 February 2018 to 10 March 2018, and from 27 April 2018 to 9 May 2018. They also complain about the Trust’s complaint response.
NHS in England Partly Upheld Jul 2025
P-003738 — United Lincolnshire Teaching Hospitals NHS Trust
Mrs M complained about the time it took for her mother to receive pain relief at the end of her life. She also complains about the timing of the Trust's investigations into her mother's symptoms and a delay in diagnosing her.
NHS in England Aug 2025
P-004304 — Royal Devon University Healthcare NHS Foundation Trust
Mrs K complains about the Trust's management of her husband's pain relief and swallow, and its delay in diagnosing and communicating that his cancer had spread to his bones.
NHS in England Partly Upheld Nov 2025
P-004390 — Leeds Teaching Hospitals NHS Trust
Ms E complains about the care and treatment her mother Ms H received from the Trust. Ms E complains the Trust missed opportunities to diagnose her mother’s cancer sooner due to delayed appointments and only scanning the upper oesophagus until July 2021. She also complaint the Trust did not give …
NHS in England Dec 2025
P-004439 — The Princess Alexandra Hospital NHS Trust
Mr P complains the Trust failed to provide appropriate bed care, investigations and treatment and pain medication to his late mother-in-law Mrs K. He also says the Trust unsafely discharged her when it realised it has inappropriately given her, end-of-life medications.
NHS in England Dec 2025
P-004784 — A practice in the Oadby and Wigston area
Ms A says the Practice placed her mother, Mrs X, nil by mouth on 14 November 2022 without a proper assessment and left her facing a potential five day wait for a SALT review. She reports that the Practice communicated poorly and took too long to respond to her complaint. …
NHS in England Upheld Feb 2026
P-001295 — Tameside and Glossop Integrated Care NHS Foundation Trust
Miss O is concerned the care and treatment given to her father (Mr O), caused him pain and led to his death. She had particular concerns about his pressure sore care, end-of-life care, bladder and bowel care, nutrition, medication, record keeping and complaint handling at the Trust.
NHS in England Upheld Feb 2022
P-001293 — United Lincolnshire Hospitals NHS Trust
Ms A complained about her terminally ill client, Mr H, not being offered a place in a hospice after being discharged from hospital, and instead being allowed to go home with no support in place.
NHS in England Feb 2022
P-001314 — The Rotherham NHS Foundation Trust
Mrs O complains about her husband being put on palliative care without consent
NHS in England Feb 2022
P-001456 — East Suffolk and North Essex NHS Foundation Trust
Mrs H complained about aspects of care and treatment her father, Mr T, received from the Trust in 2020. Specifically, she complained about his medication, treatment for bed sores, physiotherapy, applying a DNACPR and a delay in completing a CHC checklist.
NHS in England Partly Upheld Jul 2022
P-001464 — Ashford and St Peter's Hospitals NHS Foundation Trust
Miss U complains about the poor communication and misinformation she received from the Trust while her father, Mr U, was an inpatient and receiving palliative care.
NHS in England Jul 2022
P-002005 — East Kent Hospitals University NHS Foundation Trust
Mrs A complains the Trust outsourced the MRI and CT scans to a third party who reported the results incorrectly. She also complains the Trust missed an opportunity to diagnose Mr A's brain tumour and to give him palliative treatment sooner and it did not give him pain relief.
NHS in England May 2023
P-002283 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Mr D complains the Trust failed to diagnose his wife's cancer in 2019 and 2020. He also says it failed to manage her joint pain in the last months of her life.
NHS in England Upheld Nov 2023
P-002287 — Solent NHS Trust
Mrs M complains staff from the Trust failed to make sure her father had a good supply of medication for pain relief in the days before his death.
NHS in England Upheld Nov 2023
P-002809 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Miss B complains about the care and treatment the Trust gave to her mother during two hospital admissions. Miss B complains about the management of pressure ulcers, lack of MRI scan and end of life care.
NHS in England Jul 2024
P-002868 — Northern Care Alliance NHS Foundation Trust
Mrs L complains about aspects of the care and treatment the Trust provided to her mother. Mrs L says the Trust failed to provide adequate end of life care. Mrs L is also concerned about the steroid medication it prescribed to her mother.
NHS in England Aug 2024
P-003028 — A practice in the Leeds area
Mr and Mrs R complain the care home provider failed to provide good end of life care to their mother in 2019. They also complain the Practice failed to address their concerns about care during this time.
NHS in England Oct 2024
P-003274 — United Lincolnshire Teaching Hospitals NHS Trust
Ms N complains the Trust delayed her brother’s treatment for oesophagus cancer, did not tell him his prognosis was less than one year and did not show any compassion. She also complains about the compassion and palliative care.
NHS in England Jan 2025
P-003383 — Cambridge University Hospitals NHS Foundation Trust
Mr R complains about Cambridge Trust’s decision to give his wife palliative care instead of surgery. He complains about the information used to make the decision and how it was interpreted. He also complains about communication between the Trust’s, decisions made about his wife’s fitness to attend appointments and that …
NHS in England Not Upheld Feb 2025
P-003625 — Stockport NHS Foundation Trust
Mr E complains the Trust failed to provide adequate end of life care for his mother and this meant she did not have a dignified death.
NHS in England Jun 2025
P-003635 — Royal United Hospitals Bath NHS Foundation Trust
Miss X complained about the long term palliative care provided to her father, Mr X, for late-stage prostate cancer and the handling of communications around his final prognosis.
NHS in England Not Upheld Jun 2025
P-004037 — Mid and South Essex NHS Foundation Trust
Mr R complains about delays in diagnosing and starting treatment for his mother's ovarian cancer. He also complains about the delay in starting palliative care and an unsafe discharge.
NHS in England Upheld Sep 2025
P-004016 — Northern Care Alliance NHS Foundation Trust
Mrs L complains about aspects of the care and treatment the Trust provided to her mother. Mrs L says the Trust delayed providing a syringe driver and is also concerned about the steroid medication prescribed to her mother.
NHS in England Sep 2025
P-004437 — University Hospitals Bristol and Weston NHS Foundation Trust
Miss A complains about the care and treatment her aunt received towards end of life, at the end of April 2024.
NHS in England Nov 2025
P-003432 — North East Ambulance Service NHS Foundation Trust
Mr E complains the Trust delayed referring his wife to the oncology team after an appointment on 14 July 2022 and it did not give his wife adequate pain relief when she was in hospital in early August 2022.
NHS in England Partly Upheld Mar 2025
P-004434 — An independent provider in the East Hampshire area
Mrs U complains about aspects of her mother's care and treatment in March 2024. Specifically, she complains the Nursing Home did not provide her mother with end of life care medication, did not use her oxygen machine or monitor this appropriately, and used a hoist to move her out of …
NHS in England Partly Upheld Nov 2025
21-005-391c — Boots UK Limited (21 005 391c)
Summary: We consider Boots UK Limited contributed to delays getting end of life medication to Mrs C before she died. Mr B suffered avoidable distress witnessing his mother in pain before she died. Boots should pay Mr B financial redress to recognise his injustice.
LGO (Local Government & … Health Upheld Mar 2022
21-005-391 — Wirral Metropolitan Borough Council
Summary: We consider Boots UK Limited contributed to delays getting end of life medication to Mrs C before she died. Mr B suffered avoidable distress witnessing his mother in pain before she died. Boots should pay Mr B financial redress to recognise his injustice.
LGO (Local Government & … Adult Care Services Not Upheld Mar 2022
21-005-391a — The Orchard Surgery (21 005 391a)
Summary: We consider Boots UK Limited contributed to delays getting end of life medication to Mrs C before she died. Mr B suffered avoidable distress witnessing his mother in pain before she died. Boots should pay Mr B financial redress to recognise his injustice.
LGO (Local Government & … Health Not Upheld Mar 2022
NIPSO-202001016 — Western Health and Social Care TrustNorthern Ireland Hospice
The daughter of an elderly cancer patient complained that her syringe driver was removed in the days before her death, causing her to experience unnecessary pain.
NIPSO (NI Public Service… Health & Social Care Not Upheld Dec 2024
21-016-410 — The North Northumberland Hospice
We upheld a complaint about end-of-life care. The Care Provider will apologise and review its procedures for record-keeping.
LGO (Local Government & … Adult Care Services Upheld May 2022
23-013-793a — High Peak Lodge (23 013 793a)
Summary: We uphold Mrs Y’s complaint about her grandmother’s care. We found fault with Mrs X’s continence care and some aspects of her end of life care. We also found fault with the Care Home’s record keeping and the Council’s communication. As a result, Mrs X did not always receive …
LGO (Local Government & … Health Upheld Aug 2024
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