An independent provider in the Blackpool area

3. Mrs E complains about the care the Nursing Home provided to her mother, Mrs G, in January 2025.

4. She specifically complains staff: • did not manage her mother's pain medication appropriately • did not consistently manage her mother's periods of agitation and confusion • failed to safeguard her when she spoke about experiencing suicidal thoughts • did not identify her mother was approaching end of life • did not ensure her bed was made on 19 January or act on the family’s requests for assistance.

5. Mrs E says her mother had periods of pain due to staff not providing the medication sooner. She believes an increase in pain medication caused her mother periods of being highly agitated, confused and to hallucinate. As staff did not identify her mother was approaching end of life, Mrs E and her family were unable to spend time with her, and she died alone. She says the last 48 hours of her mother's life caused her mother a lot of distress and unnecessary suffering. Mrs E says knowing mistakes were made has caused her and her family considerable distress and has exacerbated their grief.

6. Mrs E wants the Nursing Home to acknowledge and apologise for the failings and make improvements to its service, so these mistakes do not happen again.

7. Mrs G was a resident at the Nursing Home from August 2024.

8. She was on palliative care and the Nursing Home’s aim was to manage her pain and keep her comfortable.

9. Staff raised a safeguarding referral on 17 December 2024 as Mrs G had expressed suicidal thoughts.

10. Mrs G sadly died on 20 January 2025.

Pain medication 14. Mrs E says if staff provided her mother’s pain medication sooner, her pain would have been managed more consistently. She tells us her mother had episodes of intense pain for around 10 minutes usually when the top up had not been administered.

15. Mrs E also tells us she believes the increase in pain medication caused her mother periods of being highly agitated, confused and to hallucinate.

16. The Nursing Home said medication charts show her mother’s pain medication was administered by staff in line with the directions of the prescribing practitioner.

17. It added that the records show night staff were regularly documenting Mrs G being in pain during the night and administering additional pain relief when required. The Nursing Home said Mrs G’s pain management was complex and staff were being supported by external healthcare professionals to ensure her pain was being managed as effectively as possible.

18. The records show Mrs G was taking regular modified release Oxeltra (oxycodone - an opioid painkiller) twice a day at breakfast and bedtime between 25 December and 19 January. It appears staff were providing this in line with prescription instructions which say one every 12 hours, but we cannot see the exact times it was given.

19. Mrs G’s doctor also prescribed oxycodone as an oral solution to be given one to two hourly, as needed for pain, with a maximum of six doses within a 24-hour period. Staff documented in her care plan and medication protocol that Mrs G was able to tell staff when she was in pain and request this herself.

20. The doctor prescribed this between 9 and 19 January on an ‘as and when’ basis when Mrs G complained about pain and not as a regular medication.

21. We can see staff administered it during these dates when Mrs G complained of pain in line with the prescribing instructions. We can also see instances where staff were asking Mrs G if she was in any pain and needed any additional pain relief.

22. This was in line with NICE guidance for ‘Patient experience in adult NHS services’ which says:

‘1.2.8 If a patient is unable to manage their own pain relief: • do not assume that pain relief is adequate • ask them regularly about pain • assess pain using a pain scale if necessary (for example, on a scale of 1 to 10) • provide pain relief and adjust as needed.’

23. Our adviser said it is very difficult to identify if an increase in pain medication caused agitation, confusion and hallucinations. This is because these symptoms are also common when someone is reaching the end of life.

24. The NHS website describes these changes in the last hours and days of life which happen to most people during the terminal (dying) phase, whatever condition or illness they have.

25. We have not seen any indication the Nursing Home staff failed to manage Mrs G’s pain medication properly or did anything wrong here. They acted in line with NICE guidance and prescribing instructions when administering pain relief medication to Mrs G. The records show staff administered Oxeltra every 12 hours and oral oxycodone when Mrs G told staff she was in pain.

Agitation and confusion 26. Mrs E says staff did not manage her mother’s periods of agitation and they wrote that she was 'refusing to go back to bed' when she was in pain and agitated. She says her mother just wanted someone to be with her and comfort her.

27. The Nursing Home said documentation shows her mother was receiving regular wellbeing checks from care staff who provided support to her when required. It said in the early hours of 18 January, the notes show her mother was unsettled and confused. The staff used techniques to try and settle her, but this did not work immediately and took some time before she did settle and fall asleep.

28. The records show that nurses provided Mrs G with regular wellbeing checks and there were occasions when she needed reassurance. It is documented that staff did provide support during these times. The nursing evaluations also show that nurses monitored and responded to her confusion.

29. We can also see Mrs G’s end of life care was also monitored by hospice nurses and nurses prescribed medication for agitation (midazolam) and staff administered it when needed.

30. This was in line with NICE guidance for ‘Care of dying adults in the last days of life’ which says:

‘1.5.8 Regularly reassess, at least daily, the dying person's symptoms during treatment to inform appropriate titration of medicine.

1.5.24 Consider nonpharmacological management of agitation, anxiety and delirium in a person in the last days of life.’

31. For example, on 11 January staff documented that Mrs G was very unsettled around 12pm. She had already taken 5mg of oxycodone an hour prior but was still unsettled so staff administered a midazolam injection. The records show by the evening, she was settled and sleeping.

32. Another example on 17 January, Mrs G woke around 12.30am and was showing clear signs of confusion as she believed staff were drugging her. Staff tried to reassure Mrs G and explained to her that this was not the case. Mrs G asked for her phone and staff gave it to her so she could call her daughter. They also asked if she was in any pain, offered pain relief and continued to monitor her through the night.

33. We recognise it was very upsetting for Mrs E to receive calls from Mrs G in a very distressed state.

34. We consider nursing staff addressed documented references to confusion and agitation in line with NICE guidance. Staff used techniques to try to calm and reassure Mrs G along with providing medications when necessary to settle her.

Safeguarding 35. Mrs E says the agency staff did not know about the safeguarding plan in place and were still leaving medications lying around.

36. The Nursing Home said her mother’s care plan evidenced the need for her medications to be administered by nurses and clearly states that Mrs G was to be supervised at all times to ensure she took her medication, even though she was deemed to have capacity.

37. It said agency staff should always familiarise themselves with residents’ care plans upon commencement of their shifts and the home staff should have also relayed this important information to them at handover.

38. The records show on 17 December 2024 Mrs G expressed suicidal thoughts advising that she would save and stockpile her pills to overdose. She had capacity to make her own decisions as per the mental capacity assessment a nurse completed on the same day.

39. The Nursing Home’s safeguarding adults policy says:

‘We should protect those adults who are unable to safeguard their own interests and are at risk of harm (including self-harm and neglect) by others because they are affected by:

• Disability • Mental disorder • Illness • Physical or mental infirmity • Misuses substances or alcohol’

40. Staff put together a care plan to mitigate the risk of intentional self-harm which included ensuring staff supervised Mrs G when swallowing her tablets to avoid stock piling. The care plan is clearly documented within Mrs G’s records for staff to see before providing care.

41. Our adviser said nursing handovers should be a structured process where the responsibility and critical information about patient care is transferred from one nurse or team to another.

42. NMC standards say:

‘8.5 work with colleagues to preserve the safety of those receiving care 8.6 share information to identify and reduce risk’

43. The Nursing Home said it has reviewed its handover documentation and has confirmed that the critical information regarding Mrs G’s suicidal ideation was not handed over as it should have been.

44. We understand this caused Mrs E to worry about her mother’s safety. We were reassured to note there was no negative impact on Mrs G as a result of the oversight which occurred, as there is no evidence from the records that her safety was breached.

45. We are pleased to see the Nursing Home recognised this as part of its complaint investigation and put actions in place to improve its service before this complaint reached us.

46. The Nursing Home said it arranged a meeting with the bank nurses to revisit its expectations and would revisit this training with agency nurses before their shifts begin to outline expectations.

47. The Nursing Home has also asked the general manager to remind staff of the important of staff handovers and carefully documenting these handovers.

48. Our Principles of Good Complaint Handling say that to put things right organisations should provide an apology, explanation, and an acknowledgement of responsibility. We say organisations should take remedial action, which may include revising procedures, policies or guidance to prevent the same thing happening again, or training or supervising staff.

49. We are reassured that the Nursing Home has acknowledged the importance of accurate staff handovers and has taken learning to prevent recurrence in line with our Principles of Good Complaint Handling. The actions should ensure staff are sharing important information within their handovers and that staff who are taking over read this information to take the correct actions.

End of life 50. Mrs E says a nurse came to check on her mother and agreed she had deteriorated but she was in a deep sleep, so they did not think there was anything to worry about. She says the nurse told her she should go home and then the Nursing Home called her a few hours later to say her mother had died.

51. The Nursing Home said there was no way to reliably predict how close the time of her passing might be despite staff having a great deal of training and experience in end-of-life care. It said it has reviewed notes from Mrs G’s final few hours after Mrs E left and there was no change noted in her breathing or pain levels. Staff also noted she was settled on each of her regular wellbeing checks.

52. NICE guidance for ‘Care of dying adults in the last days of life’ says:

‘It can often be difficult to be certain that a person is dying. The recommendations supplement the individual clinical judgement that is needed to make decisions about the level of certainty of prognosis and how to manage any uncertainty.’

53. It was documented that Mrs G was ‘lethargic most of the day’ on 20 January but was then ‘conscious and alert’ during the evening.

54. Our adviser said as this was no different to the days leading up to her death, it was not possible to say when she was in her last hours.

55. We recognise it was incredibly upsetting for Mrs E to not have been with her mother when she sadly died, when she had visited her earlier in the day.

56. We cannot criticise the Nursing Home for not reliably knowing when her mother was going to die. The records indicate her presentation was the same as it had been in previous days and as the NICE guidance reflects, predicting such things is very difficult.

19 January 57. Mrs E says in the last day of her mother’s life, the family found her slumped in the chair and because she had been sick in the night, staff had taken the bed covers off.

58. She tells us her son and nephew asked someone, at least twice, for the bed to be made up so she could be put back in her bed. However, a couple of hours later Mrs E’s two brothers arrived, and staff had still not put the bed covers on. She says they demanded staff sort it out which they did and put Mrs E back into bed.

59. The Nursing Home apologised for what Mrs G’s grandchildren saw, said it is unacceptable and staff should have actioned this swiftly. It said it was unable to understand, from the documentation, the rationale behind why Mrs G’s bed clothes were not on her bed at the time.

60. We understand it was upsetting for the family to have to ask staff for basic assistance on several occasions. The Nursing Home has accepted Mrs E’s version of events and apologised for the experience her family and Mrs G had with staff on this day. We hope this reassures her the Organisation has taken her complaint seriously.

61. We consider the Organisation has done enough in line with our Principles of Good Complaint Handling to remedy this part of the complaint. We consider this falls within level one of our Severity of Injustice scale where the effect on the individual is of short duration and there is no ongoing wider impact. We consider an apology to be an appropriate remedy for this.

1. We have carefully considered Mrs E’s complaint about a nursing home in the Blackpool area (the Nursing Home). We recognise how upsetting and distressing these events were for Mrs E and that knowing her mother was confused and agitated was worrying for her.

2. For some parts of Mrs E’s complaint, we have not seen any indication the Nursing Home got anything wrong (pain medication, managing periods of agitation and confusion, and identifying Mrs G was approaching the end of her life). For other parts of the complaint, we consider the Nursing Home has already done enough to put right the impact of these events (safeguarding issue and the events on 19 January). For those reasons, we will be not investigating further.