A practice in the Doncaster area

2. Mr F complains about the care and treatment to his mother, Mrs F, in November 2022 by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (the Trust), the GP Practice and the Care Home.

• Mr F says the Trust discharged his mother from hospital on 2 November 2022 for end of life care but did not put in place any end of life medication.

• He says the GP Practice failed to put in place end of life medication after she was discharged from hospital on 2 November 2022.

• He says the Care Home failed to ensure end of life medication was provided following her discharge from hospital on 2 November 2022.

• He also says the Care Home failed to contact his mother’s GP when the family raised concerns about her breathlessness and chest pain on 20 November 2022

3. Mr F says as a result of the failings his mother suffered an undignified and painful death rather than a peaceful death. Mr F would like the organisations to acknowledge the failings and put in place service improvements to ensure such failings don’t happen again.

4. Mrs F was admitted to the Trust on 27 October 2022 following a fall. She was discharged back to the Care Home on 2 November 2022. On 22 November 2022 Mrs F’s condition deteriorated and she sadly died in the Care Home in the early hours of 23 November 2022.

8. The GMC guidance states doctors must provide a good standard of practice and care. When assessing, diagnosing or treating patients, doctors must:

• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient

• promptly provide or arrange suitable advice, investigations or treatment where necessary

• refer a patient to another practitioner when this serves the patient’s needs.

The Trust

9. Mr F says the Trust discharged his mother from hospital on 2 November 2022 for end of life care but did not put in place any end of life medication.

10. The Trust’s discharge summary says Mrs F was admitted on 28 October 2022 following a fall and a head injury. The records indicate that when she was admitted she was also suffering with decompensated heart failure (a worsening of her heart failure) and hypoxia (a below-normal level of oxygen in the blood) which the Trust treated with oxygen therapy.

11. The Trust’s discharge summary says her blood tests were ‘unremarkable’ and her CT head scan showed no evidence of a fracture. The discharge summary says her chest X-ray identified fluid overload on her lungs which the Trust treated by increasing her regular diuretic medication.

12. The Trust’s discharge summary says following the completion of her oxygen therapy and diuretic treatment Mrs F was well enough to be discharged on 2 November 2022. In the section ‘suggested future GP management’ the Trust stated ‘none’ indicating that no specific action was required after her discharge outside her usual care.

13. Our physician adviser said on the day she was discharged the records show Mrs F’s National Early Warning Score (a tool developed which allows doctors to detect and respond to a patient’s clinical deterioration) was 0 indicating that she was not at imminent risk of her condition worsening. The records also indicate she was alert, sat up in bed, could transfer from her bed with the aid of a frame, was not suffering pain and was eating and drinking.

14. Our physician adviser said the records indicate Mrs F was not displaying any of the symptoms associated with a patient nearing the end of life at this time or at any time during her admission. Her existing health conditions continued to be actively treated and this would not be the case with a patient on end of life care as active treatment would be replaced by end of life care.

15. End of life medication is medication for the dying patient intended to alleviate the distressing symptoms of death such as pain, agitation and increased secretions. Our physician adviser said it is not routinely prescribed on discharge from hospital and would only be prescribed if the patient was discharged when their death was imminent (for example to allow them to die in their own home).

16. Our physician adviser said a doctor needs to have reasonable grounds to believe a patient is going to die very soon in order to prescribe end of life medication and there is no evidence in the records to indicate this was the case at the time the Trust discharged Mrs F from hospital.

17. Our physician adviser said the records indicate the Trust provided the treatment Mrs F needed during this admission and discharged her, to her previous active care and treatment regime, when she had recovered to her previous condition.

18. We carefully considered Mr F’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate The Trust discharged Mrs F for end of life care and no evidence to indicate the Trust should have put in place end of life medication when discharging her. We found the Trust acted in line with GMC good medical practice when discharging Mrs F on 2 November 2022.

The GP Practice

19. Mr F says the GP Practice failed to put in place end of life medication after his mother was discharged from hospital on 2 November 2022.

20. The GP Practice received a letter from the Trust dated 2 November 2022 which included a copy of Mrs F’s discharge summary. Of particular relevance to the GP Practice is the section in the Trust’s discharge summary titled ‘suggested future GP management’. In this section the Trust stated ‘none’ indicating that no specific action was requested of the GP Practice at that time.

21. Our GP adviser said there is no evidence in the records to indicate Mrs F was discharged from the Trust on end of life care. For this reason there is no evidence to indicate the GP Practice should have put in place end of life medication on her return to the Care Home on 2 November 2022.

22. The records indicate following her discharge from the Trust the GP Practice only saw Mrs F once during a routine visit on 19 November 2022. Our GP adviser said it is usual practice for a visiting GP to attend a care home regularly and be guided round by the head nurse who will inform them of the patients they think need attention from the GP. There is no evidence to indicate the GP was specifically called out to see Mrs F on this occasion due to any concerns about her health or wellbeing. The evidence indicates this was a routine care home visit.

23. The record of the visit states ‘routine home visit to review patient, no concern, remained stable’. The records provide no evidence of any concerns being raised this time about Mrs F being near the end of her life and no evidence she required end of life medication at this time.

24. We carefully considered Mr F’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate the GP Practice should have put in place end of life medication following Mrs F’s discharge from the Trust on 2 November 2022. We found the GP Practice acted in line with GMC good medical practice.

The Care Home

25. Mr F says the Care Home failed to ensure end of life medication was provided following his mother’s discharge from hospital on 2 November 2022.

26. The CQC standards state patients must:

• have care or treatment that is tailored to them and meets their needs • not be given unsafe care or treatment or be put at risk of harm that could be avoided • not suffer any form of improper treatment while receiving care

27. The NMC code of conduct states that nursing staff should be able to identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care and should make a timely referral to another practitioner (such as a GP) when any action, care or treatment is required.

28. In its response to this complaint the Care Home said it was aware Mrs F had a life limiting condition. The Care Home said Mrs F did not present as being near to death at any point until her condition deteriorated on the evening of 22 November 2022.

29. Our nurse adviser said end of life care requires a prescriber such as a hospital or GP to prescribe and issue the medication and it is not something that the Care Home could put in place. The records indicate the Trust’s discharge summary prescribed a number of medications for Mrs F on her discharge, all of which were already in stock at the Care Home. Our nurse adviser said these were routine medications to be taken every day for a variety of conditions such as blood pressure, thyroid, cholesterol, water tablets, constipation, diabetes, pain relief and blood thinners. Our nurse adviser said none of the medications prescribed in the Trust’s discharge summary were end of life medications.

30. The records indicate Mrs F’s condition was generally stable from 2 November 2022 to the afternoon of 22 November 2022, shortly before she died. The records indicate on almost every day, she ate breakfast, lunch and an evening meal and drank fluids throughout the day. The records also indicate she was well enough to spend time in the lounge. Our nurse adviser said there is no evidence in the records of Mrs F displaying any end of life symptoms until her condition deteriorated on the evening of 22 November 2022.

31. We carefully considered Mr F’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate the Care Home should have taken any action to ensure end of life medication was put in place following Mrs F’s discharge from the Trust on 2 November 2022. We found the Care Home acted in line with the CQC standards and NMC code of conduct.

32. Mr F says the Care Home failed to contact his mother’s GP when the family raised concerns about her breathlessness and chest pain on 20 November 2022.

33. In its response to this complaint the Care Home said a staff member checked on Mrs F after speaking with the family and found her condition to be normal, alert and responsive and when asked if she had any chest pain the Care Home said she answered no. The Care Home said the staff member completed standard visual observations and had they felt Mrs F was in distress, would have acted on this. The Care Home said Mrs F was calm, had good colour, was not breathless when she was talking to the staff member and was able to follow the conversation.

34. The records for 20 November 2022 show the Care Home assisted Mrs F with her personal care and dressing in the morning. She was able to take her medication and had some food and drink. The records show the Care Home assisted her to the bathroom during the day and she spent some time in the lounge with other residents.

35. Her family then attended and spent some time with Mrs F. Following the visit, at 4.36pm the records indicate the Care Home checked on Mrs F while she was in the quiet lounge and noted she appeared to be her normal self, alert, responsive and breathing normally. There is no indication in the records that Mrs F was experiencing chest pain at that time.

36. The records indicate the Care Home monitored Mrs F throughout the remainder of the evening and assisted with her evening meal and evening routine. The records provide no evidence of any deterioration in Mrs F’s health on 20 November 2022 and there are no entries in the records of any concerns about her health that would require the Care Home to contact her GP.

37. We carefully considered Mr F’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate it was inappropriate for the Care Home not to contact Mrs F’s GP when the family raised concerns on 20 November 2022. We found the Care Home acted in line with the CQC standards and NMC code of conduct.

1. We have decided to not uphold this complaint. We acknowledge how upsetting these events were for Mr F and that they continue to cause him considerable distress. We did not find any indication of failings in the care, treatment and clinical decision making of the Trust, the GP Practice or the Care Home.