An independent provider in the Worcester area

3. Mr G complains about the actions of the Hospice when caring for Mr X from 10 – 20 August 2024.

4. Mr G says: • no staff were available when he called for help as Mr X was dying • staff did not provide medication to relieve his suffering, and; • the Hospice’s complaint response incorrectly stated Mr G, along with three staff members, were with Mr X when he died.

5. Mr X had a history of cancer which sadly could be cured. On 20 August 2024, Mr G accompanied Mr X to the Hospice for end of life care, as he had deteriorated rapidly at home, with increased secretions (fluids that accumulate in the airways towards the end of life) and agitation.

6. The night before, Mr X had required several “just in case” medications (medications to relieve symptoms at the end of life) from a nurse during a home visit. Because of this, staff were concerned that he may not survive the transfer to the Hospice but decided to authorise this, as it would bring Mr G some comfort.

7. Once at the Hospice, Mr X remained unconscious until his death. Mr G states that during this time, the Hospice did not give Mr X midazolam (medication for agitation) to relieve his symptoms, as the Hospice had run out of their supply. The Hospice state they gave Mr X a combination of midazolam, morphine (strong painkiller) and hyoscine butyl bromide (medication for secretions at the end of life) during his final hours.

8. At the time of Mr X’s death, Mr G could not find any staff to help him, despite pressing the call bell. He ran into the corridor shouting for help while leaving Mr X alone, which he didn’t want to do. Staff responded in four minutes, and report that there were three staff members, as well as Mr G, with Mr X as he died.

9. Mr X died at 9.15pm on 20 August 2024.

13. 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.

14. We have done this and have not found any indication that something has gone wrong in this case. We appreciate that this decision will be upsetting for Mr G and understand the impact the circumstances surrounding the loss of Mr X must have had on him. Below, we will explain the reasons for our decision in more detail.

Issue 1 – the Hospice did not provide medication to relieve Mr X’s suffering

15. In his formal complaint, Mr G states that the Hospice did not provide Mr X midazolam, a drug used for sedation at end of life, on the day that he died. He believed this was because they had run out of their supply.

16. In the response dated 23 September 2024, the Hospice explained they reviewed the medication supply from 20 August 2024 and there were 132 vials in stock.

17. The Hospice stated Mr X’s syringe pump contained 15 mg of midazolam, as well as 10mg of morphine sulphate and 120mg of hyoscine butyl bromide. A syringe pump is a medical decide that delivers a continuous flow of medication.

18. Mr X’s syringe pump chart dated 20 August 2024 notes that these medications were replenished on the unit at 6.30pm. The patient records say the dose of midazolam was increased from 10mg every 24 hours to 15mg every 24 hours, to ease Mr X’s agitation. Two members of staff signed that they put the relevant medications into the syringe pump.

19. According to NICE end of life guidance, the Hospice should have assessed what medications Mr X may need to manage symptoms (such as agitation, pain and respiratory secretions) and review these as his needs changed.

20. In his patient record from 20 August 2024, Mr X was described as appearing ‘very comfortable’, based on his facial expressions, at 6.45pm. The records also indicate that the increased doses in his syringe driver were effective. For example, increasing the dose of hyoscine butyl bromide at 8.05pm for his secretions was appropriate. This suggests that the Hospice did assess Mr X’s needs throughout his in-patient stay, which we hope eases some of Mr G’s anxieties surrounding his treatment.

21. In summary, the medications administered to Mr X whilst he was an in-patient were appropriate, correct and in line with NICE guidelines. We hope the confirmation that midazolam was used brings Mr G some comfort, as we appreciate how difficult it would be to imagine Mr X was not medicated properly.

Issue 2 – no staff were available when Mr G called for assistance as Mr X was dying

22. During our telephone call, Mr G confirmed that he believed the staffing levels at the Hospice were inadequate, which led to nobody being available as Mr X was dying.

23. Despite ringing the call bell to alert staff he needed assistance, Mr G stated he had to leave Mr X’s room to try and find somebody to help him, as nobody responded.

24. In the response dated 30 October 2024, the Hospice said they have four members of staff working on the unit each night, which they believe is sufficient. The Hospice said on 20 August 2024, there were two nurses and two healthcare assistants on shift.

25. The Hospice confirmed all the staff were present on the unit when Mr G pressed the call bell. This is supported by the nursing notes and the record of door access from 20 August 2024.

26. There is no set nurse to patient ratio for care outside intensive care and high dependency units, as so many factors influence staffing. NICE staffing levels guidance states the main driving factor for calculating staff levels is individual nursing needs.

27. Given that staffing levels are based on a whole group of patients, it is not possible to determine whether the number of nurses on shift at the Hospice were sufficient. However, the evidence we have seen suggests Mr X’s needs were met and he remained comfortable until his death, which suggests the levels were adequate.

28. While it is not possible to determine the time period between when Mr G pressed the call bell and when a nurse was found, Mr G stated that after two minutes he left Mr X’s room to search the lobby. The Hospice’s response dated 23 September 2024 states a nurse was with Mr G within four minutes.

29. Based on both of these accounts, it is reasonable to assume the timeframe between Mr G pressing the call bell and a nurse being present was around four minutes.

30. In an interview dated 23 October 2024, a nurse stated they were three doors down from Mr X’s room, administering medication to another terminally ill patient, when they heard Mr G shouting for help. The nurse said they finished administering medication to the patient before responding to Mr G.

31. We deeply appreciate how distressing it was for Mr G to have to wait for this administration of medication to be completed, as it must have felt like a very long time. The nurse did follow the NMC policy, as they have to complete medication before attending to another patient. This is because the NMC policy says nurses must take all steps to keep medicines stored securely. If they had not finished giving the medication to the other patient, they would have had to take steps to secure the medication before attending to Mr X.

32. From the records and statements, it appears there was no undue delay in responding to Mr G when he pressed the call bell, though we appreciate how distressing It must have been when nobody was immediately available.

Issue 3 – the Hospice incorrectly stated that Mr G was accompanied by three staff members in the room as Mr X died

33. In his account of events, Mr G states that by the time he found a nurse and made it back to Mr X’s room, Mr X had passed away. Mr G says he was extremely upset by this, as he had promised Mr X he would not die alone. He said a nurse said to him Mr X was “now dead” and “beyond help”.

34. According to the Trust’s response dated 30 October 2024, a qualified nurse and two healthcare assistants accompanied Mr G in Mr X’s room as he died. They state that all members of staff recall Mr X taking his last breaths for around a minute, before reassuring Mr G and documenting Mr X’s death at 9.15pm. They all recall Mr X being peaceful and not agitated in the moments leading up to his death.

35. Sadly, there are no other records, such as door access or CCTV, which would help us determine on balance which account is correct. We are left with two different accounts from Mr G and the Trust regarding what occurred in Mr X’s final moments.

36. It is important to explain our role is to make independent final decisions about NHS complaints in England. We make decisions by weighing up and considering all the available evidence. We then consider the likelihood that something has gone wrong with the service provided. As we are impartial, we must make robust decisions based on facts and evidence.

37. Unfortunately, without further evidence, we are unable to reach a decision as to whether staff were on the scene at the time of Mr X’s death. For this reason, we are unable to take any further action.

38. We recognise how frustrating this must be for Mr G, and we are sorry we cannot provide him with closure for his concerns around this element.

39. We appreciate the time and effort it takes to complain to us, and we would like to thank Mr G for bringing this to our attention. While we are sorry this is not the outcome Mr G was hoping for, we hope he can find some comfort in the reassurance that Mr X was comfortable as he died, and that was the result of Mr G’s determination to get him the support he needed in his final hours.

1. We have carefully considered Mr G’s complaint about the Hospice. We understand that Mr G has concerns about staffing levels, medication distribution and how the staff respond to alerts for help within the Hospice. As a result, Mr G believes his civil partner (Mr X) did not have adequate support during the last moments of his life, and Mr G could not be in attendance himself due to trying to find a staff member to help him. We acknowledge how distressing this situation must have been for Mr G and offer our sincere condolences for his loss.

2. Having considered Mr G’s complaint, we see no indication of failings from the Hospice during Mr X’s time as an inpatient. This is because they followed appropriate guidelines and policies when providing medication and support to him. We recognise this will be disappointing news for Mr G., This report explains our reasoning in more detail.