A practice in the Hillingdon area

The Practice 6. Mrs D complains the Practice missed opportunities to further investigate and diagnose her mother, Mrs P, with lung cancer between January and July 2021.

7. She says the lack of action from the Practice meant her mother’s diagnosis was delayed and this impacted her eventual sad outcome. She feels that different action may have led to an improved outcome for her mother and this thought causes her significant distress.

8. She says her mother was in a great deal of pain and her quality of life in her last few months was awful. She says her mother did not feel listened to by the Practice and this was extremely difficult for Mrs D to witness. She wants an acknowledgement of failings, service improvements and a financial remedy.

The Trust 9. Mrs D complains the Trust failed to communicate effectively about her mother’s diagnosis and prognosis during her admission between 21 and 27 August 2021 or fully inform the family in a timely manner that her mother was sadly dying in September. She also complains it failed to provide her mother with a private room or adequate pain relief during the end of her life in September.

10. She says the lack of communication from the Trust meant that her and her family were unprepared for her mother’s sad death. She told us the inadequate pain relief meant that her mother was in unnecessary pain and discomfort at the end of her life which was extremely distressing to witness.

11. Mrs D says the lack of private room for her mother meant she did not have the privacy and dignity that she deserved at the end of her life, and this was a horrible experience for the family. She told us this experience was extremely traumatic for her and her family, and it has impacted her ability to gain closure following her mother’s sad death. She wants an acknowledgement of failings, service improvements and a financial remedy.

12. This very brief background is only intended to place the key events in context, not to provide a full, chronological account of everything that happened.

13. Mrs P had a past medical history of diabetes, hypertension, hyperthyroidism, and had a benign breast lump removed 10 years ago. She contacted the Practice on 20 January 2021 due to pain in her upper arm that extended into her right breast and armpit. The Practice carried out a breast examination on 21 January and arranged blood tests and an X-ray to investigate.

14. On 15 February, Mrs P contacted the Practice as she continued to experience pain. She requested a referral to the Breast clinic, and the Practice actioned this request on the same day. The Breast clinic at the Trust reviewed her on 2 March. Her breast examination was normal, and a mammogram did not show any new suspicious features. The Breast Team discharged her back to the Practice.

15. Mrs P contacted the Practice on 3 March due to her ongoing pain, and it referred her for a musculoskeletal (MSK) opinion on the same day. An MSK team diagnose and manage muscle, joint, and bone problems. On 11 March, Mrs P contacted the Practice to request stronger pain relief, and it prescribed co-codamol. On 22 March, it gave Mrs P a topical non -steroidal anti-inflammatory (nsaid) cream to try and manage her pain.

16. On 1 April, Mrs P contacted the Practice and requested stronger pain medication due to her ongoing pain, and it prescribed pregabalin (a medication to relieve pain). On 13 April, the Practice increased this prescription when she reported ongoing pain.

17. On 29 April, the Practice adjusted Mrs P’s medication and trialled her on tramadol (a medication to relieve pain) as she experienced side effects with pregabalin. On 30 April, Mrs P contacted the Practice as her pain was worse, and it reinstated the pregabalin medication as she preferred this.

18. Mrs P contacted the Practice on 21 May as her right breast was very painful, and she had a new lump in her armpit. The Practice referred her to the Breast clinic at the Trust on the same day, on a suspected breast cancer referral pathway.

19. The Trust’s Breast Team reviewed Mrs P on 3 June and found she had accessory (additional) breast tissue in the right armpit. On the same day, Mrs P contacted the Practice and requested stronger pain medication or a higher dose due to her ongoing pain. The Practice gave her a higher dose of pregabalin.

20. On 5 July, the Practice reviewed Mrs P’s pain relief and increased this as she continued to experience severe pain. Mrs P was reviewed by the MSK team at the Trust on 7 July. It found a 2cm lump in her armpit and arranged an urgent ultrasound.

21. The Trust admitted Mrs P due to jaundice on 20 July. On 27 July and following a biopsy of the lump in the right armpit, the Trust decided that Mrs P’s likely diagnosis was lung cancer. It discussed her case at the multidisciplinary team (MDT) meeting and confirmed a lung cancer diagnosis on 29 July. It informed Mrs P of her diagnosis on 30 July and discharged her on 2 August as she was well enough to go home.

22. The Trust carried out an endoscopic retrograde cholangiopancreatography (ERCP) on Mrs P on 20 August to investigate the cause of her jaundice. An ERCP is a flexible tube with a camera on the end that is passed down the food pipe, into the stomach and first part of the small intestine. It admitted her on 21 August due to abdominal pain following the ERCP. The Trust discharged Mrs P on 27 August. On 2 September the Trust admitted Mrs P as she was short of breath. Mrs P sadly died on 4 September.

25. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

The Practice

Investigations / referrals 26. Mrs D told us her mother attended the Practice on numerous occasions with symptoms and significant pain, and this should have been a red flag to it, that something was seriously wrong. She says the Practice missed an opportunity to do more and it did not listen to her mother. Mrs D believes if the Practice had taken different action, her mother may not have sadly died.

27. We were sorry to hear Mrs D’s concerns about how the Practice investigated and managed her mother’s symptoms before she was sadly diagnosed with lung cancer in the July. From what she told us, it was clearly a significantly distressing time for her and her mother, and her concerns about how the Practice managed her mother’s care before her sad death, continues to cause her ongoing distress.

28. NICE guidance on suspected cancer says refer people using a suspected cancer pathway referral for lung cancer if they have chest X-ray findings that suggest lung cancer, or they are age 40 and over with unexplained haemoptysis (coughing up blood). It says to offer an urgent chest X-ray for people aged 40 and over to assess for lung cancer if they have two or more of the following symptoms: cough, fatigue, shortness of breath, chest pain, weight loss, and appetite loss.

29. The guidance goes on to give advice about suspected breast cancer referrals. It says refer people using a suspected cancer pathway referral for breast cancer if they are aged 30 or over and have an unexplained breast lump with or without pain or aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction, or other changes of concern. It also says to consider a suspected cancer pathway referral for breast cancer for people aged 30 and over with an unexplained lump in the arm pit.

30. GMC guidance says doctors must provide a good standard of practice and care, adequately assessing the patient’s conditions and promptly provide or arrange suitable investigations where needed. It also says to refer a patient to another practitioner when this serves the patient’s needs.

31. On 20 January, Mrs P contacted the Practice as she had pain in her right upper arm that extended into her armpit and into the right breast. The Practice reviewed her at a face-to-face appointment on 21 January and carried out a breast examination. It documented this was normal, although Mrs P’s right breast was tender to touch. It planned to carry out a blood test and an X-ray of her humerus (the long bone that runs between the shoulder and the elbow) to investigate her symptoms.

32. Our GP adviser explained that when Mrs P attended the Practice on 21 January, she did not present with any of the symptoms listed in the NICE guidance above that would suggest a referral for suspected cancer was needed at this stage.

33. From what we have seen, the Practice’s actions at this appointment appear to be in line with the NICE guidance on suspected cancer because at this point, Mrs P did not present with any of the symptoms listed above from the NICE guidance (such as a breast lump or weight loss) that would trigger the need for an urgent referral to either the breast or lung team for review.

34. We consider the Practice followed GMC guidance when it planned to carry out a blood test and an X-ray for Mrs P in the first instance, as it promptly arranged suitable investigations to further investigate the cause of her symptoms.

35. Mrs P’s X-ray and bloods did not show anything unusual, however, she was experiencing worsening pain on 15 February. She reported not having any masses in her breast, but that her right breast was tender, and her pain medication did not fully resolve her pain. The Practice referred her to the Breast Team for review on the same date, as her symptoms were not improving despite conservative treatment.

36. The Breast Team at the Trust reviewed Mrs P on 2 March. As her breast examination was normal and a mammogram did not show any suspicious features, the Trust did not find any signs of breast cancer, and it discharged her back to the Practice.

37. On 3 March, Mrs P was still experiencing pain in her right arm and arm pit. She also reported chest pain at this appointment although it appears the main source of her pain was coming from her arm and arm pit. The Practice referred Mrs P to the musculoskeletal (MSK) team on the same day for its opinion. It appears it did this as Mrs P continued to have pain in her arm and the Breast clinic had been clear that the pain was not related to her breast.

38. Our GP adviser explained that sometimes arm pain can be referred nerve pain from other parts of the body such as the neck. They went on to say that it appears the Practice did not have any reason to suspect her symptoms may be linked to lung cancer at this point as she did not have any of the red flag symptoms of lung cancer that are suggested in the NICE guidance above such as an ongoing cough or coughing up blood.

39. Considering what was recorded in the medical records about Mrs P’s symptoms, test results, and our clinical advice, it appears the Practice followed GMC guidance on referring a patient to another practitioner when this serves the patient’s needs. This is because it referred Mrs P to another practitioner to further investigate her ongoing symptoms when the Breast Team reassured it that her pain was not coming from her breast.

40. On 21 May, Mrs P was awaiting a review from the MSK team, however, she presented at the Practice with a new lump in her right arm pit and worsening breast pain. The Practice referred her to the Breast clinic promptly, on the same day. This action appears to be in line with the NICE guidance above as Mrs P presented with a new red flag symptom that is listed in the guidance to trigger a suspected breast cancer referral.

41. The Breast Team saw Mrs P on 3 June and explained that she had additional breast tissue in the right armpit. It said this was not the cause of her pain but offered to remove it. It also noted she was waiting to see the MSK team about her ongoing pain.

42. Mrs P saw the MSK team on 7 July and it arranged an urgent ultrasound of her right arm pit as it found a 2cm lump. Following a biopsy of the lump, the Trust sadly diagnosed Mrs P with lung cancer on 27 July.

43. Based on what we have seen and the clinical advice, it appears the Practice followed relevant GMC and NICE guidelines when it referred Mrs P to relevant specialists based on her presenting symptoms and when she met the threshold to trigger a suspected cancer referral. We cannot see any evidence that it missed earlier opportunities to do this as it promptly referred her to MSK and the Breast Team for further investigations, in line with GMC guidance.

44. We consider the Practice would not have considered the possibility of lung cancer due to Mrs P’s presenting symptoms, therefore, we cannot say it should have diagnosed her with lung cancer or referred her to a lung specialist. We are therefore satisfied the Practice followed the relevant NICE guidance based on her presenting symptoms.

45. It is understandable that Mrs D feels the Practice did not listen to her mother when she contacted it on numerous occasions between January and July due to the amount of pain she was in. She believes this should have been an indication to the Practice that something was seriously wrong with her mother. It is clear that her concerns continue to cause her ongoing distress, and we were sorry to hear this.

46. The medical records show that Mrs P contacted the Practice on at least eight occasions between March and July to discuss her ongoing pain and to request pain relief to help manage it. We have seen evidence the Practice attempted to manage her pain with different medications each time she contacted it.

47. We recognise Mrs D feels Mrs P's reports of increased pain should have raised concerns with the Practice.  Based on all the information we have seen, we do not consider Mrs P’s contact with the Practice about her pain, as missed opportunities for it to further investigate her symptoms. This is because, as we have found above, it actioned referrals as and when it was necessary, and she had either seen or was waiting to be seen by the relevant specialists.

48. Based on the evidence we have seen and the clinical advice, we have seen no indication that anything went wrong in investigating Mrs P’s symptoms between January and July 2021. We consider the Practice followed relevant guidelines when it assessed her presenting symptoms and referred her to specialists for further investigations.

49. We recognise it must be extremely worrying for Mrs D to have concerns about the care her mother received from the Practice before her sad death, and we do not underestimate her experience. From what she told us, it is clear that she has been through a very difficult and sad time.

50. We hope our findings and the information from our clinical adviser, helps to clarify anything she was unsure of and gives her some reassurance that the Practice followed relevant guidelines when it managed her mother’s care. We will therefore take no further action on this complaint for this reason.

The Trust

August admission 51. Mrs D complains the Trust did not communicate her mother’s diagnosis or prognosis to her or her family during her admission between 21 and 27 August 2021. She says her mother’s cancer had spread everywhere by August, but the Trust did not tell the family this. She says its communication about her mother's condition was poor and this meant that her family were not prepared for her mother’s sad death.

52. We were sorry to hear Mrs D’s concerns about how the Trust communicated with her mother and her family at what must have been a very difficult time for them all. From what she told us, it is clear that this experience was very worrying for Mrs D, and she continues to experience distress following her mother’s sad death.

53. Our physician adviser explained that there are no specific guidelines on how to communicate a cancer diagnosis. However, NICE guidelines on patient experience say clinicians should give patients (and their family members if appropriate) clear, consistent, evidence-based, tailored information throughout all stages of their care. This includes information on their condition and any treatment options.

54. On 20 July 2021, the Trust admitted Mrs P due to jaundice. During this admission, it had a conversation with Mrs P and Mrs D on 27 July to discuss the results of the biopsy it took from the lump in her arm pit earlier in the month. It explained that the results showed a likely diagnosis of lung cancer, however, it wanted to discuss her case in a multidisciplinary team (MDT) meeting.

55. An MDT is a group of health care professionals who work together to make decisions on the care and treatment of individuals. The Trust discussed Mrs P’s case at the MDT on 29 July and confirmed that Mrs P’s biopsy showed lung cancer.

56. On 30 July, the Trust documented a conversation with Mrs P. It said it had a formal discussion with Mrs P and her husband about her lung cancer diagnosis and planned for her to see the oncology team in outpatients following a planned ERCP procedure to investigate the cause of her jaundice. From what we have seen in the evidence, it appears the Trust made Mrs P aware of her lung cancer diagnosis during this discussion on 30 July. It discharged Mrs P on 2 August.

57. Based on what we have seen, we consider the Trust followed NICE guidelines on patient experience here as we can see evidence that it gave Mrs P and her family clear, consistent, and evidence-based information when it told her on 27 July that the biopsy showed a likely diagnosis of lung cancer, but this needed to be discussed by the specialists at an MDT, and then on 30 July after this discussion that she had lung cancer. We cannot say with certainty what was actually said on these occasions or how this was understood by Mrs P and her family, but it does appear the diagnosis was discussed with them.

58. The Trust carried out an ERCP for Mrs P on 20 August to investigate the cause of her jaundice. A day later on the 21 August, it admitted Mrs P as she had abdominal pain following the ERCP. It carried out a CT scan of Mrs P’s abdomen and pelvis on the same day and diagnosed her with pancreatitis (inflammation of the pancreas) and a new pulmonary embolism (where a blood clot blocks a lung artery).

59. We have seen evidence that Mrs P was reviewed by the lung cancer nurse and a palliative care consultant during her August admission. Neither team appeared to be concerned that her cancer disease was progressing or worsening. On 26 August, the Trust documented that Mrs P was well enough for chemotherapy and the oncology team planned to review her as an outpatient following her discharge. It discharged her on 27 August.

60. Our physician adviser explained that the CT scan during Mrs P’s admission did not show any new findings to suggest a worsening of her prognosis. They went onto say that there was no indication during that admission that there had been a deterioration in her cancer condition and the Trust still planned to treat Mrs P with chemotherapy following her discharge.

61. Based on what we have seen and the clinical advice, it appears the Trust did not think Mrs P’s cancer had progressed during this admission and therefore, we do not consider it withheld any information from Mrs P and her family.

62. It appears the Trust followed NICE guidance on patient experience here, as it gave Mrs P information about her diagnosis on 30 July and its treatment plan. This information does not appear to have changed during her August admission as it still planned the same treatment for her. Based on this, we have seen no indication that anything went wrong.

63. We hope our findings and the explanations from our physician adviser help to reassure Mrs D that the Trust did not withhold information from her and the family, and it does not appear it was concerned about a deterioration in her mother’s condition during her August admission.

September admission

Communication 64. Mrs D complains the Trust failed to fully inform the family in a timely manner that her mother was sadly dying during her admission in September 2021 and this meant that her and her family were unprepared for her mother’s sad death.

65. We were sorry to hear about Mrs D’s experience before her mother’s sad death and how this distressing this was for the family. From our conversations with Mrs D, this was clearly a very upsetting time.

66. NICE guidance of the care of dying adults says good communication of a dying person's prognosis improves their end-of-life care and the bereavement experience of those important to them. It explains that clinicians should provide the dying person and those important to them, with accurate information about their prognosis.

67. The Trust admitted Mrs P on 2 September as she was short of breath. In the early of hours of the morning on 3 September, it documented that Mrs P’s shortness of breath had worsened in the last 24 hours, she was unable to complete full sentences, and she looked very unwell. It explained that her condition had progressed, and she was sadly approaching the end of her life.

68. It telephoned her husband to update him and explained that she was very unwell and likely to sadly die in the next few hours, rather than days. It advised him to visit her if he wanted to. The Trust had a further conversation with Mrs P’s family at 12.15pm on the same day and explained that Mrs P had a poor prognosis, she had deteriorated, and she was approaching the end of her life. This appears to be in line with the NICE guidance above as the Trust appears to have communicated her prognosis to her family effectively and accurately.

69. Our physician adviser explained that it appears the Trust informed Mrs P’s family about her deteriorating condition at the earliest opportunity and it does not appear it could have done this any sooner.

70. Based on the evidence we have seen, it appears the Trust followed NICE guidelines and informed Mrs P’s family that she was approaching the end of her life as soon as it recognised her condition was deteriorating.

71. We were sorry to hear that Mrs D and her family felt unprepared for her mother’s sad death as we imagine this was an extremely distressing experience for them. We hope our findings and the information from our physician adviser, goes some way to help reassure her that the Trust followed relevant guidelines when it told her that her mother’s condition had deteriorated as soon as it was able to.

Private room 72. Mrs D is understandably concerned that the Trust did not give her mother a private room at the end of her life. She explained that this meant she did not have the privacy and dignity that she deserved, which was a horrible experience for the family.

73. Our physician adviser explained that there are no national guidelines to say when a patient should be assigned a side room during end-of-life care. However, NICE guidance on the care of dying adults says care should be focused on maintaining the person's comfort and dignity. Our physician adviser explained that staff are expected to move patients at the end of their life to a side room to ensure a private and dignified death.

74. It appears the Trust reviewed Mrs P at 3pm on 3 September and her family were at her bedside. The Trust told Mrs P and her family that she was close to sadly dying and the family understood this. They requested a side room for Mrs P. The medical records document Mrs P was moved to a side room at 7.31pm (approximately four hours after the family requested one).

75. Based on this information, it appears the Trust followed NICE guidance on the care of dying adults as it listened to Mrs P’s family’s request for a side room and provided this to maintain her comfort and dignity without a prolonged delay. We cannot say the Trust should have done this any sooner as there are no guidelines to say it should and we have seen no indications that anything went wrong when the Trust managed Mrs P’s family’s request for a side room and provided one when it was able to.

76. Sadly, Trusts are not always able to facilitate requests for a side room straight away. In this case we can see how a four hour wait caused significant distress for her family. We were sorry to hear about this unfortunate circumstance and the fact the Trust was not able to ease this distress at the time.

End of life pain relief 77. Mrs D complains the Trust did not give her mother adequate pain relief during the end of her life. She says her mother was in a lot of pain during the end stages and this was distressing to witness. She thinks this could have been avoided with different action from the Trust and she will never get over this.

78. From what she told us, it is clear that Mrs D’s experience of her mother’s sad death continues to cause her ongoing distress, and we are sorry to hear that she thinks her mother may have had a less painful experience with different action from the Trust.

79. NICE guidance on the care of dying adults says if pain is identified during the end-of-life stages, it should be managed promptly and effectively. It says to consider using a syringe pump/driver to deliver medicines for continuous symptom control and to seek specialist palliative care advice if the dying person's symptoms do not improve promptly with treatment.

80. As above, we have identified that the Trust considered Mrs P was sadly approaching the end of her life in the early hours of the morning on 3 September as her condition was deteriorating. It arranged for the palliative care team to carry out a review of Mrs P and prescribed anticipatory medication (medication prescribed to patients towards the end of their life to manage symptoms such as pain and nausea).

81. The palliative care team reviewed Mrs P a few hours later at 9.50am. At this stage, it appears Mrs P did not have any pain however, she was short of breath and frightened. The team suggested using a syringe driver (a small device that gives a steady flow of medicines to help manage symptoms) and said staff should create a comfort care plan (a plan to ensure a person’s physical and emotional needs are taken care of so they remain comfortable towards the end of their life).The Trust noted that the family were content with Mrs P’s care at this stage.

82. We can see that the Trust completed a comfort care plan on the same day and prescribed a syringe driver to deliver pain relief. In Mrs P’s case this was morphine (a strong pain killer to treat severe pain) and midazolam (a sedative).

83. At 3pm, the palliative care consultant and the lung cancer nurse specialist reviewed Mrs P and increased the medication dosage in her syringe driver as she was experiencing pain. The palliative care consultant explained to the family that Mrs P could also have further medication to help calm her down and she will get sleepier during the following part of the end-of-life process.

84. At 7.31pm it is note that Mrs P was in distress (which was distressing for the family to witness), so the Trust gave her the prescribed medication frequently to help manage this. It documented that it emotionally supported the family who did not raise any complaints about the care it provided at the time.

85. On 4 September at 3.49am, Mrs P’s family requested that the dose of medication in the syringe driver was increased as she was agitated. The Trust requested a review from a doctor. At 11.02am, a doctor reviewed Mrs P as her family were concerned that she was intermittently agitated and in pain. The doctor reassured Mrs P’s family and increased the dose in the syringe driver and the rate of the doses. It appears that Mrs P was not in pain during this review and was comfortable. Mrs P sadly died at 3.40pm.

86. Sadly, some patients can still experience pain despite pain relief during the end-of-life process. The Marie Curie website explains that some people experience pain and discomfort in their last days of life and although medicines should help make it more manageable, the pain may not go away completely. Signs of pain might include changes in mood, agitation, and distress.

87. Our physician adviser explained that palliative care team reviewed Mrs P during the end stages of her life. They explained that the team increased her pain medication in the syringe driver and the rate of the doses, and it appears it did this to help manage Mrs P’s symptoms.

88. Based on the information we have seen and the clinical advice, it appears the Trust followed NICE guidelines on the care of dying adults. This is because we have seen evidence that it managed her pain promptly and used a syringe driver to do this. It also sought specialist palliative care advice when the palliative care consultant reviewed Mrs P and her symptoms. We have seen no indication that anything went wrong when the Trust provided pain relief for Mrs P during the end of her life.

89. It is understandable that Mrs P’s sad death was extremely distressing for Mrs D and her family. It is clear from the medical records that Mrs P was scared and frightened during the end of her life, and we imagine this was significantly difficult and upsetting for Mrs D to witness. We hope our explanations and the information from our physician adviser helps to reassure her that the Trust followed relevant guidelines when it managed her mother’s end of life care.

Conclusion 90. We have considered Mrs D’s complaints about the Practice and the Trust, and we have found no indication that anything went wrong. Based on what we have seen and the clinical advice, we consider the Practice followed relevant guidelines when it assessed her presenting symptoms and referred her to specialists between January and July 2021.

91. We also consider the Trust followed relevant guidelines when it communicated to Mrs P and her family during her admissions in August and September and provided her with a private room and pain relief during the end of her life. Therefore, we will take no further action on these complaints.

92. It is understandable that this experience has been extremely distressing for Mrs D. From what she told us, her mother’s sad death has massively impacted her life. We hope our findings and the information from our clinical advisers, helps to clarify anything she was unsure of and gives her some reassurance that the Practice and the Trust followed relevant guidelines when it managed her mother’s care.

1. We have carefully considered Mrs D’s complaint about the Practice and The Hillingdon Hospitals NHS Foundation Trust (the Trust). We were sorry to hear Mrs D’s concerns about her mother’s care before her sad death and how she felt different action may have led to a different outcome. From what she told us, this experience has been significantly upsetting for her and her concerns about the Practice’s and the Trust’s actions clearly continue to cause her ongoing distress.

2. Mrs D is understandably concerned with how the Practice investigated her mother’s symptoms between January and July 2021, given her mother’s sad death. She complains it missed opportunities to investigate and diagnose her mother with lung cancer. We were sorry to hear Mrs D’s concerns about the Practice’s actions. Based on the information we have seen, it appears the Practice followed relevant guidelines when it investigated Mrs D’s mother’s symptoms, and we have seen no indications that anything went wrong. We have therefore decided to take no further action for this reason.

3. Mrs D complains about the Trust’s communication with her and her mother between August and September 2021. She also complains it took too long to provide a private room for her mother and did not manage her pain before her sad death in September. We were sorry to hear Mrs D’s concerns about the Trust following her mother’s diagnosis.

4. Based on the information we have seen, it appears the Trust followed relevant guidelines when it communicated with Mrs D and her family, and when it managed Mrs D’s mother’s care before she sadly died. We have seen no indications that anything went wrong, and we have decided to take no further action for this reason.

5. We recognise how important this complaint is to Mrs D, and we do not underestimate how distressing her experience has been. We would like to take this opportunity to thank her for bringing her complaint to our attention. We hope our explanations below show how we have considered this complaint, and gives her some reassurances that the Practice and the Trust followed relevant guidelines