Salisbury NHS Foundation Trust

4. Miss S complains that between 10 and 18 May 2024 staff at the Trust failed to diagnose her father, Mr S, with a pulmonary embolism (PE).

5. Miss S also complains staff gave her father end of life drugs, morphine and midazolam, without her knowledge or consent.

6. Miss S says due to the delay in diagnosis, her father was denied the choice of being treated for his condition which could have prevented his sudden death. Miss S also says the provision of morphine and midazolam hastened her father’s death. Miss S states the suddenness of her father’s death, and the misdiagnosis, has caused her considerable distress.

7. As an outcome to the complaint, Miss S would like the Trust to acknowledge any failings in the treatment of her father and apologise for the distress this has caused. She would also like the Trust to improve its service.

8. Miss S’s father, Mr S, was in his nineties and terminally ill with Acute Myeloid Leukaemia (AML). AML is a type of cancer affecting the blood cells which can progress very quickly. He was receiving supportive treatment of twice weekly platelet transfusions and weekly red cell transfusions. Doctors were not planning any active treatment, and they had referred him to the palliative care team.

9. On 10 May Mr S attended hospital for a day admission to receive a blood transfusion. It is around this time Miss S says his symptoms of increased breathlessness begun. On 14 May Mr S again attended hospital to receive a blood transfusion. The doctor treated him for a chest infection and prescribed him with antibiotics and he was discharged.

10. On 17 May Mr S attended hospital again to receive a blood transfusion. The doctors did not give Mr S platelets due to blood tests showing his platelet count to be good.

11. In the late hours of 17 May due to her father’s worsening shortness of breath, feeling bloated and coughing up blood, Miss S took him to the emergency department, where he was admitted into hospital.

12. Mr S sadly died on 18 May. His cause of death was pulmonary embolism (a blood clot in the lung), acute myeloid leukaemia and frailty of old age.

16. Before we decide if we should investigate a complaint in more detail, we look at a few different factors. We consider whether there are signs the organisation concerned has got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell far short of what should have happened, we call this a failing. We have done this and we think there was a reasonable alternative explanation for Mr S’s breathlessness initially. Therefore, we think doctors were right to think it was a symptom of his known conditions. We also think morphine and midazolam were given at an appropriate time because sadly, Mr S was dying by that point, and these drugs were given to ease any discomfort or distress he may have experienced.

Pulmonary embolism

17. Miss S told us her father was attending hospital regularly between 10 and 17 May 2024, when he developed breathlessness, which she believes were the early signs of a PE. She believes, that had the symptoms been identified earlier her father could have received treatment before his condition became too severe.

18. The Trust said that Mr S’s symptom of breathlessness was consistent with a chest infection, his leukaemia, and his anaemia. The Trust explained that even if the diagnosis for the PE had been made earlier, Mr S could not have been treated with anticoagulants (blood thinning medication) due to his low platelet count and associated risk of bleeding.

19. Our adviser told us that NICE 158 is applicable in this scenario. This says what doctors should do to identify a deep vein thrombosis (DVT – blood clot forming in a deep vein) or PE in patients presenting with symptoms of either condition. It notes that symptoms of PE include breathlessness, which Mr S had, as well as coughing up blood and chest pain, which he did not initially have.

20. Our adviser explained that it is common for patients, like Mr S, who have AML and anaemia (low count of healthy red blood cells) to present with shortness of breath. They explained that in the absence of any other symptoms, such as coughing up blood, or signs suggesting a DVT, it would be reasonable to assume that his symptoms were in keeping with anaemia and needing a blood transfusion.

21. The records document that Mr S’s symptoms of breathlessness began as early as 8 May. However, it was not till the late hour of 17 May where he reported additional symptoms of feeling bloated and coughing up blood. It was at this point Mr S was admitted into hospital, and doctors diagnosed his PE.

22. As Mr S was not showing symptoms indicating a PE, and there was a more likely explanation for his symptoms, we do not think doctors were wrong in not looking into the possibility of PE further until his symptoms changed. It is not possible to know either way whether the initial breathlessness he presented with was an early sign of the PE or whether doctors were right to consider it to be his anaemia. However, we asked our adviser to tell us whether the Trust was right when it said that even if a PE were present and diagnosed, it could not have been treated in Mr S’s case.

23. Treatment for PE involves giving anticoagulation (blood thinning) medication to the patient. Our adviser explained blood thinning medication should be avoided if it is not possible to consistently keep the platelet count above a certain level. A platelet count is the measure of the number of platelets in a volume of blood, crucial for clotting and preventing bleeding.

24. Our adviser explained that Mr S’s records show he had a consistently low platelet count. That being the case, very sadly, it would not have been possible to treat Mr S with blood thinners due to the risks of excessive bleeding.

25. We understand how upsetting it has been for Miss S to wonder if her father should have been treated earlier. We hope our explanation helps provide clarity and reassurance about why a PE was not suspected sooner, and why, even if it had have been, sadly, there would have been nothing that could have been done to treat it.

End of life drugs

26. Miss S said that on 18 May after her father’s initial admission to hospital, she returned home believing her father was stable and was being treated by the doctors for a chest infection. She said whilst she was away the doctors prescribed her father with end-of-life drugs morphine and midazolam without her consenting or being informed this was happening. She says the combination of the two drugs hastened her father’s death.

27. The Trust explained that Mr S demonstrated full capacity throughout his treatment. They said that Mr S told staff he wanted to avoid prolonged hospital admissions, have good pain management and expressed a preference for balancing extending life with comfort and valued outcomes. It said that notes showed that the next of kin was advised of his deterioration and the plan for palliative care. The Trust explained that morphine and midazolam were prescribed to Mr S to ease his distress and pain.

28. We looked first at the appropriateness of giving Mr S morphine and midazolam. Our adviser referred to NICE 31. This states that when considering symptom control, medical professionals must consider the dying person’s preference alongside the benefits and harm of the medication.

29. Our adviser also referred to the Resuscitation Council UK Respect document, which states that if patients have capacity, then the conversation about clinical care and treatment should be with them. Our adviser said the patient may invite family to be a part of the discussion, but they explained this is designed for patients in a planned care setting and not in the Emergency Department. Our adviser said that with regards to ReSPECT form discussions, family members can be consulted for their knowledge of the patient’s wishes but are not entitled to make legally binding decisions unless they hold power of attorney.

30. Our adviser explained that Mr S’s condition deteriorated and at 8:44am he had a confirmed diagnosis of PE. Doctors concluded that he was approaching the end of his life and prescribed anticipatory medications – morphine and midazolam. Anticipatory medications are drugs prescribed to patients nearing the end of life to manage symptoms. At 8:55am doctors advised that the anticipatory medications should be given.

31. Our adviser said the medication recommended for helping with breathlessness and agitation, which Mr S had, is an opioid (painkiller) and/or a benzodiazepine (sedative medication). They said Mr S received a combination of these in the form of morphine and midazolam which was appropriate given his symptoms. They confirmed the dosage prescribed to Mr S was in keeping with that recommended by the British National Formulary.

32. We are, therefore, satisfied that doctors appropriately gave Mr S morphine and midazolam to be able to quickly manage his sudden and distressing symptoms during the final stages of his life.

33. The records document that on the morning he died, that Mr S was alert but speaking in short sentences. A ReSPECT form discussion took place with Mr S at 6.38am. A ReSPECT form discussion is a conversation between the patient and healthcare professional to create a treatment plan based on the patient’s preference, values and clinical needs, for when they may not be able to make or express choices. It is recorded that he did not want to be resuscitated and wanted to be made comfortable if he deteriorated.

34. Mr S had capacity at the time of the ReSPECT discussion and it was, therefore, appropriate for doctors to discuss his ongoing care and treatment directly with him. We recognise it was incredibly unfortunate that this conversation took place when the family were not present at the hospital. This can happen in an emergency care setting, where, as in Mr S’s case, patients can deteriorate suddenly. We have already set out that the morphine and midazolam were given to make Mr S comfortable. Therefore, we consider that, in giving the end-of-life medications when his condition deteriorated, the doctors acted in accordance with Mr S’s consent and his wishes. As Mr S had capacity to make his own decisions and had clearly expressed his wishes for his care, no further consent from Miss S was required when his condition deteriorated.

35. We went on to consider whether staff appropriately communicated to Miss S that they were giving her father the end-of-life medications. Good Medical Practice says doctors must be sensitive and responsive when giving support and information to those close to the patient. In this instance, we think ‘responsive’ meant giving Miss S important information as soon as possible.

36. At 8:44am when anticipatory medications were prescribed to Mr S, the notes stated that Mr S’s daughter was now aware and coming in. This means staff told her about this at the earliest possible moment. At 8:55am when the anticipatory medication was given to Mr S, a staff member recorded that they tried to call Miss S but that she did not answer. Again, we think staff were appropriately keeping, or attempting to keep, Miss S informed of the rapidly unfolding events. At 9:30am Miss S rang the emergency department. The notes state that Miss S became upset and when she was told her father was likely dying, she was keen the hospital did all they could for him.

37. We appreciate that the phone call regarding her father’s deterioration must have been both distressing and confusing, given how unexpected it was. We recognise her belief that doctors should have asked for her consent to give her father the end-of-life drugs, but that was not the case. What doctors needed to do was keep her updated as soon as they could, and the evidence shows that they did that.

38. We hope our explanation gives Miss S some reassurance that the doctors looking after her father acted at the right time to make her father comfortable, in line with his wishes.

1. We have carefully considered Miss S’s complaint about Salisbury NHS Foundation Trust (the Trust).

2. It is entirely possible that Mr S had a PE in the days before he died and that this is what was causing him to become breathless. Therefore, we fully acknowledge why Miss S had concerns about his care and treatment. There were, however, other more likely causes for his symptoms and there was no clinical need for doctors to suspect a PE before they did. Sadly, even if they had diagnosed a PE earlier, there was nothing they could have done to treat it. We also consider that morphine and midazolam were administered to her father with his consent, and that these were appropriate medications to ease any discomfort or distress he may have experienced at the end of his life. We hope that knowing this provides Miss S with a small degree of comfort.

3. We have explained our decision in detail below.