The Christie NHS Foundation Trust

15. This background is intended to place the key events in context, not to provide a full account of everything that happened.

16. On 17 December 2023 Ms T started with abdominal pain. This led to Trust A performing a Computed Tomography (CT) scan. A CT scan is a medical imaging procedure that uses a combination of X-rays and a computer to create detailed, cross-sectional images of the inside of the body. The scan, and a biopsy, detected a rare form of appendix cancer.

17. On 28 February 2024, Ms T had an appointment with the oncologist at Trust A. They discussed potential treatment options for her cancer. The oncologist discussed the possibility of starting oral chemotherapy medication to see if there was any benefit. The oncologist arranged a blood test on this day to check for potential side effects of the oral chemotherapy medication.

18. The same day, a nurse performed a blood test. Ms T began to feel very unwell, and staff suspected she may have had a stroke. Staff transported her urgently via ambulance to Trust B for assessment. She had left sided weakness, facial droop, dysarthria (difficulty speaking because the muscles you use for speech are weak) and confusion. Trust B undertook a CT head scan. It diagnosed her with a cancer-associated stroke and admitted her to hospital.

19. On 29 February Trust B prescribed cyclizine (an anti-sickness medication) to treat Ms T’s sickness symptom and administered it regularly from 1 March. The speech and language therapy (SALT) team reviewed her on this date. They advised she could swallow modified diet and fluids (changing the consistency of food and drinks to make them easier and safer to swallow for people with swallowing difficulties).

20. On 2 March, Ms T started vomiting persistently.

21. On 4 March, Trust B suggested inserting an NG tube to ease Ms T’s vomiting symptoms. There were difficulties in inserting it, and it successfully inserted it on 11 March. The NG tube drained a large amount of her stomach contents.

22. On 11 March, Trust B accidentally administered midazolam to Ms T instead of levomepromazine (medication used to treat nausea and vomiting). The Palliative Care Team noticed this error on 12 March, and amended the prescription, stopping the midazolam. It reviewed Ms T and found she had no adverse side effects.

23. On 19 March, Trust B discharged Ms T, and she went home.

24. On 12 April, Ms T sadly died.

1. We were sorry to hear about Ms R’s concerns about her mother’s care. We understand this was, and continues to be, very distressing for her. We offer our sincere condolences on the sad loss of her mother, Ms T.

2. We have carefully reviewed Ms R’s complaint about the care and treatment Trust A and Trust B provided to Ms T.

3. Our finding is Trust A took her mother’s bloods correctly. It did not cause her mother to have a stroke. We have also found nothing in the records to suggest her mother had a venous air embolism. It was appropriate for Trust A to not offer Ms T chemotherapy following her stroke on 28 February.

4. We do not consider Trust A refused for Ms T to have steroids or refused scans.

5. Our finding is Trust B gave Ms T adequate nutrition and hydration and consider it treated her vomiting appropriately.

6. Our view is Trust B delayed in fitting a nasogastric (NG) tube. That is a thin and flexible tube inserted through the nose, down the throat and into the stomach to provide nutrition, hydration and medication. We found the delays were not a failing in the care it provided. This is because there were valid reasons behind the delays, and it attempted to fit it when safe to do so.

7. Our finding is Trust B gave Ms T midazolam (a drug commonly used to produce sleepiness or drowsiness) when it should not have. We have carefully reviewed what action Trust B has since taken and consider it has done enough to put this right.

8. We do not uphold Ms R’s complaint. Our findings are detailed below.

The complaint about Trust A 9. Ms R complains about the care and treatment her mother, Ms T, received from Trust A between 28 February and 5 March 2024. Specifically, she complains it:

• took a blood test incorrectly which caused her mother to have a stroke • did not offer her treatment for her cancer • refused for her mother to have steroids which she feels could have eased her pain • refused further scans (for her stomach).

10. Due to this, she says:

• her mother died prematurely • it caused severe psychological impact to her as she is constantly thinking about the Trust’s failings.

11. As a result of complaining to us, she is seeking:

• acknowledgement of failings • service improvements • financial redress (level six on SOI scale).

The complaint about Trust B 12. Ms R complains about the care and treatment her mother, Ms T, received from Trust B from 28 February 2024 to 19 March 2024. Specifically, she complains it:

• did not give her mother sufficient nutrition or hydration • did not treat her severe and constant vomiting • delayed in fitting an NG tube • incorrectly administered midazolam.

13. Due to this, she says:

• her mother died prematurely • it caused severe psychological impact to her as she is constantly thinking about the Trust’s failings.

14. As a result of complaining to us, she is seeking:

• acknowledgement of failings • service improvements • financial redress (level six on SOI scale).