The Princess Alexandra Hospital NHS Trust

3. Ms B complains about the care provided to her father, Mr C, by The Princess Alexandra Hospital NHS Trust (the Trust) from 9 to 12 June 2024. Specifically:

• Mr C was overdosed on morphine when he was in hospital.

4. Ms B says the acknowledged overdose of morphine contributed to her father’s death on 12 June 2024, as reflected by his Death Certificate. Ms B says that a consultant involved in her father’s care altered his medication prescription without any clear rationale for the change. This resulted in a morphine overdose for her father that many experienced nurses administered without anyone realising the damage it was causing. As a direct consequence of this tragic experience, Ms B and her family have suffered immense pain and loss. Ever since her father died, Ms B has been living with Post Traumatic Stress Disorder (PTSD), anxiety and depression due to the trauma and having to experience such a horrendous situation in hospital involving her father.

5. As a set of outcomes, Ms B wants a formal apology from the Trust and further explanation about what happened to her father and why they experienced such a horrifying situation. Ms B also wants changes in procedure at the Trust to prevent this from happening to another patient and a financial remedy of at least £12,500.

6. Mr C was 76 years old. He had a background of advanced metastatic bladder cancer and had recently been in hospital. It had been recognised that he was approaching the end of his life. Mr C was taken to hospital by ambulance on 9 June 2024 due to shortness of breath and he was admitted with bilateral community acquired pneumonia.

7. Mr C was prescribed regular morphine sulphate 10 mg twice daily from 9 June 2024. This was then changed on 10 June 2024 to 10mg 4-hourly. Mr C received five doses in total.

8. By 6.46am on 11 June 2024, Mr C was found to have a NEWS2 score of 10. His arterial blood gases showed decompensated type 2 respiratory failure, and Mr C’s Glasgow Coma Score was 5/15. Mr C was given Naloxone with only a partial response.

9. Sadly, Mr C was found unresponsive at 4.14am on 12 June 2024. Mr C’s cause of death was Type 2 Respiratory Failure, Community Acquired Pneumonia, Advanced Clinical Frailty, Disseminated Bladder Cancer and Inadvertent Morphine Overdose.

11. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. We have discussed this with Ms B to understand her circumstances and the outcomes she wants for her complaint about the Trust. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

12. The Trust said in its Patient Safety Incident Rapid Review Form that it is unlikely the patient’s (Mr C’s) death was preventable during this admission due to his frailty and advanced metastatic cancer. However, the Trust also acknowledged that Mr C’s death may have been hastened due to the inadvertent overdose of morphine.

13. Therefore, we appreciate the potential injustice for Mr C and his family including Ms B, as Mr C sadly died just three days after initially being prescribed morphine. This is a tragic situation for Ms B and her family which they are all struggling to deal with.

14. We note that one of Ms B’s desired outcomes for her complaint is financial remedy of at least £12,500. This would be level 6 on our scale of injustice which is the highest level. Ms B has informed us that she has decided to take legal action against the Trust and has been in touch with solicitors to take this forward.

15. Given this, we consider Ms B has a cause of action (medical negligence), and she should still be in time to take such action. Overall, we consider that Ms B has a reasonable ALR to resolve her complaint about the Trust.

16. We do remain an option for considering Ms B’s complaint against the Trust, but only if the legal route does not cover some parts of her complaint that we can realistically consider. Therefore, in accordance with our processes, we must close Ms B’s Ombudsman complaint. Ms B can come back to us at the end of the legal process if she remains dissatisfied, but there is no guarantee we will be able to further consider any outstanding issues or achieve the outcomes she is seeking.

1. We have carefully considered Ms B’s complaint about The Princess Alexandra Hospital NHS Trust.

-We consider Ms B could take legal action on the matters that she has brought to us.

2. We recognise that what happened to Mr C when he was in hospital was unexpected and his sad death is a tragedy for Ms B and her family. We understand why Ms B brought her complaint to the Ombudsman, but we consider Ms B has a reasonable Alternative Legal Remedy (ALR) to resolve her complaint about the Trust.