A practice in the Wiltshire area

3. Ms O complains about the care and treatment the Practice provided to her partner, Mr M, in January 2025 before he sadly died. She complains between 28 to 30 January the GP failed to provide adequate pain relief medication.

4. Miss O says as a result he suffered in unbearable pain in the last few days of his life and did not have a peaceful death. She says she and her son are both still traumatized by the experience.

5. As a result of bringing the complaint to us, Miss O is seeking service improvements and a financial remedy.

6. Miss O’s partner, Mr M was diagnosed with terminal liver cancer in November 2024.

7. After his diagnosis and being treated in hospital, Mr M was discharged home on 11 November with a prognosis of having weeks left to live. The plan was that he would get district nurse home visits and hospice visits.

8. On the GP's Christmas eve home visit, the GP prescribed an 'emergency pack' to leave in the house which contained 3 different types of pain medications.

9. Mr M died on 30 January 2025.

10. Ms O complained to the Practice on 12 February 2025, and the Practice sent its final response on 31 May 2025. Ms O brought her complaint to us on 22 September 2025.

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 any indications that something has gone wrong.

15. Mrs O complains between 28 to 30 January the GP failed to provide adequate pain relief medication to her partner, Mr M when his pain worsened. She says he had a respect form on file which specifically stated he did not want to die in pain. She says when they requested more effective pain relief from 28 January it should have been immediately provided given that he was dying and suffering so much. Instead, they were made to wait whilst he was in agony.

16. Ms O says the lack of adequate pain relief given in the last few days of his life meant he suffered unbearable pain and did not have a peaceful death. This was also traumatic for her and her son to witness.

17. The records show the GP went to visit Mr M at home on 24 December and prescribed ‘just in case medications’ (JIC). This included Oxycodone medication for pain.

18. In the evening of 28 January, Ms O called the district nurses who were delayed in coming out so instead, the out of hours GP visited to insert a catheter and gave an injection of the Oxycodone from the JIC box. This is an opioid medication used to treat moderate to severe pain, it changes how a patient feels pain by blocking pain signals in the body.

19. On the morning of 29 January, Ms O called the nursing team to ask for help with Mr O’s increasing pain and they liaised with the palliative care consultant from the hospice. In response to this, a syringe driver was set up with an increased dose of oxycodone. Once the Practice received this prescription, it wrote a new drug chart which it sent to the district nurses and sent a further prescription of 20 ampoules of Oxycodone to the pharmacy.

20. At this time, the pharmacy only had one ampoule of Oxycodone in stock which was issued, with the rest to follow. This was only enough to cover the overnight period and not the increased amount needed for further top up doses as per the new drug chart.

21. By the evening of 29 January, Mr M’s pain increased and he required further top up doses of Oxycodone. As there were no more ampoules left, the out of hours team attended to give doses from their stocks. The rest of the prescription was collected on 30 January, the morning Mr M died.

22. NICE guidelines on the care of dying adults says;

‘Medicines are sometimes prescribed in advance for symptoms that might happen in the future. These medicines are often called ‘just in case’ medicines and may be provided in a specially marked container called a ‘just in case’ box. Providing medicines in advance means that there is no delay in getting medicines that might be needed quickly to help with symptoms. This may be particularly important for people who are not in hospital’.

23. We asked our adviser what pain medication should have been prescribed to Mr M from 28 January onwards. Our adviser says there is no definitive guidance on what medication to use for end-of-life care but in line with above guidance, it would be usual practice to have a pain killer, anti-sickness medication and something to calm agitation and these are known as ‘just in case’ (JIC) medicines.

24. We can see these medications were prescribed by the Practice on 24 December to be kept at Mr M’s home and used as and when needed. The records show these medications were used on 27/28 January and a further supply requested on 29 January.

25. In general terms, pain relief should be prescribed on a regular basis, in addition to as required pain relief, and follow a stepwise approach, using the World Health Organization analgesic ladder;

• Step 1: non-opioid analgesic such as paracetamol and/or nonsteroidal anti-inflammatory drug (mild pain) • Step 2: weak opioid such as codeine, dihydrocodeine, or tramadol (controlled drug), with or without non-opioid analgesic (mild-to-moderate pain) • Step 3: strong opioid such as morphine, with or without non-opioid analgesic (severe pain).

26. Oxycodone is a step 3 strong opioid and Mr M was also given morphine by the out of hours doctor on 28 January.

27. Unfortunately, the delay in Mr M receiving the additional medication from 29 January appears to be due to supply issues at the pharmacy, which were out of the Practice’s control.

28. Having considered the records and clinical guidance, we can see the appropriate pain medication was prescribed to Mr M by the Practice in advance of his anticipated worsening pain.

29. The Practice acted in line with the NICE guidelines when arranging the ‘JIC’ box and responded appropriately to contact from the patient and to requests for medication from fellow health professionals.

30. We recognise the supply issue at the pharmacy would have caused additional distress at an already very difficult time and do not underestimate this. However, we have not found any indications of failings in the Practice’s actions in Mr M’s pain relief care.

31. Unfortunately, at the end of life despite using all medications available patients can sadly still die in pain. It is clear from the notes the Practice did what it could to address Mr M’s pain and unfortunately it was more difficult to manage due to all the different parties involved in his care, the supply issue at the pharmacy, and the fact he was at home rather than in a hospital setting.

32. Complaints give us a valuable insight into the organisations we investigate, and we recognise this was a very distressing time for Ms O and her son. We would like to thank her for sharing her experience with us.

1. We have carefully considered Ms O’s complaint about the Practice and the pain relief medication it provided to her partner, Mr M. We were very sorry to hear about the circumstances of her complaint and the sad loss of Mr M.

2. We have not seen any indications of failings in relation to the actions of the Practice in its provision of pain medication. This is because we have seen the Practice carried out pain relief care and treatment in line with guidance. We have explained the reasons for our decision below.