Mersey and West Lancashire Teaching Hospitals NHS Trust

5. Mr Q complains about the care and treatment his late wife, Mrs Q, received from the Trust from 4 October till 6 October 2023. He specifically says the Trust:

• did not appear to know what medication Mrs Q was on before the admission, and Mr Q had to relay that information along with specific amounts • kept Mrs Q in hospital an extra night instead of discharging her to the local hospice • overdosed Mrs Q on medication during her stay.

6. Mr Q believes Mrs Q faced unnecessary pain from the whole experience which she could have avoided if the Trust had sent her back to the Hospice earlier. Mr Q also found the situation very distressing himself, especially seeing Mrs Q in a lot of pain and then overdosed on medication. Mr Q is concerned the high doses of medication led to Mrs Q having a stroke when she was transferred to the Hospice, in the days before she died.

7. By bringing this complaint to PHSO, Mr Q seeks an apology, an in-depth explanation of events, and financial remedy.

8. Mrs Q was a woman in her seventies with a history of incurable lung cancer. In September 2023 Mrs Q was admitted to a hospice for pain management. The hospice were planning Mrs Q’s discharge home when she developed symptoms of a stroke on 4 October. The hospice sent Mrs Q to the Trust’s hospital for assessment by the stroke team.

9. The Trust treated Mrs Q’s stroke with thrombolysis (medication to dissolve blood clots) and blood thinning medication. The Trust transferred her back to the hospice on 6 October.

10. Mrs Q developed symptoms of another stroke on 9 October, and sadly died on 13 October 2023.

14. 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 indications that anything has gone wrong.

Prescribing medication during admission

15. Mr Q complains the hospital staff did not know what medication to prescribe Mrs Q during her emergency admission on 4 October 2023. He says the staff did not have the relevant notes at the time, so he had to provide this information along with the required amounts they had to administer.

16. From the records provided by the hospital, we can see the ambulance transferred Mrs Q from the hospice due to suffering a stroke on 4 October 2023. The notes further state that Mrs Q was crying in pain and unable to communicate properly due to dysphasia (ability to produce and understand spoken language). We recognise that it must have been incredibly difficult for Mr Q to witness this.

17. The records confirm that Mr Q told the ward staff that Mrs Q was receiving 15mg of subcutaneous (injection given into the fat under the skin) oxycodone (an opioid based pain killer) for breakthrough pain before her admission to the hospital.

18. GMC guidance says doctors must promptly provide or arrange suitable treatment where necessary. It also says doctors must only prescribe drugs when they have adequate knowledge of the patient’s health and are satisfied the drugs serve the patient’s needs, and that the treatment is compatible with any other treatments the patient is receiving.

19. Our advisor stated the Trust appropriately considered Mrs Q’s medical history on arrival, which is present in the Hospice handover records to the Trust. The hospital staff were prioritising treating Mrs Q’s stroke as it was time critical for them to make these decisions and provide relevant care. The Trust provided thrombolysis treatment which has to be given as quickly as possible to maximise the effectiveness.

20. Our adviser said it is quite common for some of the patient information to not be available at the point of admission, which the hospital usually clarifies over the next day or so. Therefore, the staff relying on Mr Q for assistance to clarify Mrs Q’s medication is understandable in this situation. This helped the Trust make a timely decision about thrombolysis treatment.

21. While we understand how stressful and distressing it was for Mr Q to provide this information while seeing Mrs Q in pain, the evidence shows the Hospital staff acted in line with GMC standards by prioritising her stroke as emergency and taking all available steps to prescribe the correct medication based on the information that was available in that moment.

22. We can see no indications of failings in the Trust asking Mr Q to provide information about his wife’s medication. We hope Mr Q is reassured the Trust did this to avoid delay in treating her stroke.

Keeping Mrs Q an extra night

23. Mr Q says the Trust kept Mrs Q in hospital for an extra night and returned her to the hospice on 6 October 2023. He explains that staff told him Mrs Q would ‘more than likely’ be returning on 5 October 2023, but this did not happen. He also says staff told him the hospice had a 2 pm cutoff time for accepting patients, which he disputes as he did not feel this should apply to Mrs Q’s circumstances.

24. The hospice records and the Trust’s complaint responses show the Trust kept Mrs Q for an additional night because she was experiencing increased pain. Other hospital notes confirm the team initially intended to discharge her on 5 October 2023 but decided not to as they did not think transferring her at that point would be in her best interests given her poor condition.

25. Our adviser explained there is no specific national guidance on transferring patients between providers, so the relevant standard is the GMC’s requirement to provide a good standard of care and to take all possible steps to alleviate pain and distress. This includes basing decisions on the patient’s needs, priorities, and the likely effectiveness of treatment options.

26. Upon investigation, we can see the Trust has explained this to Mr Q in detail in their complaint responses. The hospital staff reviewed Mrs Q on 5 October 2023 with a view to discharging her to the Hospice. However, during the review Mrs Q was crying in pain, rubbing her leg, and unable to communicate properly due to dysphasia.

27. The Trust decided that they wanted to observe if they could control the pain and whether she would be suitable for speech and language therapy and occupational therapy assessment the next day. The Trust amended her medication to help with her pain. On 6 October 2023, the staff noted Mrs Q was not well enough for an input from the Hospital’s therapy team, so the Trust transferred her back to the hospice at 1.30 pm, hoping the hospice’s therapist would be able to review her appropriately.

28. We understand Mr Q disputes the Hospice’s 2 pm cut‑off time. However, the Hospital cannot transfer a patient to a provider that is not able to accept patients after a certain time. This is why the Trust arranged for Mrs Q’s transfer before the cut‑off time the following day.

29. Our adviser explained that transferring Mrs Q to the hospice when she was in significant pain on 5 October would not have been in her best interests. This is because moving her in and out of an ambulance, and travelling by road, would all have increased her pain. As such it was in line with GMC guidance to keep Mrs Q in hospital for an extra night while staff tried to control her pain.

30. We realise Mr Q is upset that the Trust did not stick to the commitment of returning Mrs Q to the Hospice on the date initially stated, and this caused him a lot of concern regarding Mrs Q’s well-being. We are sorry for his experiences. We hope our decision reassures Mr Q about why we believe the Trust have done enough to explain the decision‑making around her additional stay and delayed transfer.

Excessive medication caused a stroke

31. Mr Q complains the Trust gave Mrs Q increased doses of medication during her lengthened stay at the Hospital. He believes the excessive amount caused her to overdose and experience a stroke after she returned to the hospice. We understand how distressing and upsetting this was for Mr Q.

32. Mr Q says he is unsure why the Hospital staff gave midazolam (medication used to relieve anxiety) to Mrs Q during her stay. He also states increasing her dose of oxycodone before the Trust discharged her to the hospice was another leading cause in her deteriorating health.

33. The Trust responded to Mr Q’s queries about midazolam by stating the hospital staff had this as a part of their ‘just in case medications’. They prescribed this to Mrs Q to help her relax and calm down in response to her painful symptoms.

34. The Trust also confirmed during Mrs Q’s admission she received 5 mg of oxycodone and two further similar doses on 5 October 2023. Following a review by the staff of her symptoms, they gave her a further 10 mg dose of oxycodone as the previous doses had not been effective. On 6 October 2023, the staff further increased the doses of oxycodone to 15 mg as the previous doses did not effectively relieve Mrs Q of her severe pain and distress. They kept the syringe driver at 60 mg per 24 hours. Before her discharge, the staff increased the syringe driver oxycodone dose to 80 mg as they felt Mrs Q was nearing the end of her life.

35. As per NICE stroke guidance, it does not list opioid toxicity as a stroke risk factor. Our advisor confirmed opioid toxicity is usually fully reversible and would not be expected to cause a stroke.

36. Our adviser explained the decisions around prescribing opiates and midazolam were made by specialist care staff who were monitoring Mrs Q closely. The clinical notes show the team documented her symptoms in detail and adjusted her medication in response to her significant pain and agitation. Our adviser also highlighted there is no fixed maximum dose for opiates, instead doses are increased gradually and safely to match the patient’s level of discomfort. This approach is standard practice in end‑of‑life care.

37. Our adviser confirmed there is no clinical evidence to suggest the doses Mrs Q received were inappropriate or unsafe. They considered it more likely that Mrs Q’s pre‑existing and serious underlying health conditions were responsible for her stroke and overall deterioration, rather than the medication the staff gave her to manage her symptoms.

38. We fully recognise how distressing this experience was for Mr Q, particularly as he witnessed Mrs Q in considerable pain and saw the staff increasing her medication over a short period of time. It is understandable that this caused confusion and concern about whether the treatment may have contributed to her decline.

39. However, based on all the evidence available we have not found a link between the Trust’s actions and Mrs Q experiencing a stroke. The medication changes appear to have been appropriate, clinically justified, and in line with recognised care practice. While we appreciate the emotional impact this situation had on Mr Q, the evidence does not indicate that the Trust’s care caused or contributed to Mrs Q’s stroke.

40. We appreciate the time and effort involved in raising these concerns and we thank Mr Q for bringing his complaint to our attention. We hope our explanation brings some reassurance that the care and treatment provided by the Trust to his wife was in line with the relevant standards.

1. We have carefully considered Mr Q’s complaint about the care his late wife, Mrs Q, received from Mersey and West Lancashire Teaching Hospitals NHS Trust (the Trust).

2. We are very sorry to hear Mr Q feels the staff at the Hospital did not know what medication to prescribe for Mrs Q during her admission. We understand why this caused him concern. Our review has not identified any evidence that the Trust acted outside relevant standards. We explain this in more detail below.

3. We understand Mr Q is also upset the Trust inappropriately kept Mrs Q in hospital an extra night instead of discharging her to the Hospice. Based on the evidence reviewed, we have not seen any indications the Trust did anything wrong and was acting in Mrs Q’s best interests. We explain the reasons for our decision below.

4. We recognise how important this complaint is to Mr Q and acknowledge the distress he experienced around Mrs Q’s death. We are sorry to hear he feels the Trust gave excessive medication to Mrs Q in hospital which led to her stroke after she was discharged to the Hospice. This is a sad case. We have not seen any indications the Trust did anything wrong, or that we can link the Trust’s actions to Mrs Q experiencing a stroke. We explain the reasons for our decisions in more detail below.