An independent provider in the Canterbury area

4. Mrs H complains about the Hospice and the care and treatment her husband Mr E received on 22 November 2024. Specifically, she complains: • in the last 24 hours of his life, the Hospice failed to manage his pain appropriately • the doctor had assumed that the pain medication was available when it was not • there was no communication around her husband’s medication.

5. She also complains about the handling of her complaint. The Hospice did not adhere to its own complaint procedure, did not keep her updated and had not established a clear process to make a complaint, poor follow-up, sent her correspondence addressed to her in the wrong name and incorrectly signposted to the wrong panel member.

6. Mrs H was terribly upset and distressed watching her husband suffer unnecessarily in the last hours of his life. She found the complaint handling process difficult which caused her unnecessary distress and wasted time.

7. Mrs H is looking for service improvements.

8. Mr E was discharged on 14 November from the hospital back home and to receive support from the Hospice as an outpatient. He was under the care of his own GP but received visits from the Hospice doctors.

9. On 15 November he received a home visit from the Hospice doctor. The doctor noted Mr E had been discharged home with insufficient amounts of medication for his syringe driver. The doctor completed an urgent prescription for oxycodone (pain medication) and for Mr E's wife to collect the medication from the hospital.

10. From 16 to 21 November, Mr E received daily visits from the community district nurse and the Hospice at home doctors to provide full care and the Hospice at home doctor.

11. On 22 November, Mr E sadly died at home.

Pain management

15. Mrs H told us that the Hospice failed to appropriately manage her husband’s pain, because in the last 24 hours of his life, he was in a lot of pain. We acknowledge this was a distressing and upsetting time for Mrs H to have to watch her husband suffer at the end.

16. No set guidance exists for managing pain in dying patients as it is a case-by-case basis. The GMC guidance, paragraph six, states that doctors must provide a good standard of practice and care, work in partnership with others to assess patients’ needs and priorities. Doctors must propose, provide or prescribe drugs or treatment only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs.

17. NICE guidance NG31 managing pain, paragraph 1.5.10 to 1.5.14 states pain in the last days of life should be assessed regularly and proactively, using both verbal reports and non-verbal signs, with input from family and carers where needed. Pain relief should be individualised and reviewed frequently, ensuing appropriate use and dose adjustment of analgesics, including opioids, based on effectiveness, side effects, and the person’s overall condition. Anticipatory prescribing, including medication for breakthrough pain, is recommended so pain can be treated promptly, and specialist palliative care advice should be sought if pain is complex or not adequately controlled.

18. We reviewed an extract of Mr E’s medical records and sought clinical advice. On 15 November, the day the hospital discharged Mr E home, he was discharged with insufficient medication for his syringe (metoclopramide 90mg to treat nausea and vomiting). In response, the Hospice doctor issued a prescription for oxycodone (opioid medication to manage pain) for Mrs H to collect from the hospital pharmacy to ensure continuity of pain management.

19. On 17 November the community adult nurse requested stat injections (medication delivered by shot that must be administered immediately, without delay) for pain relief and anti-sickness medication for Mr E. On 18 November, at approximately 9am, it is recorded that Mr E was experiencing significant pain, and the community nurse made a request for the GP to attend. At 9.25am, documentation noted that Mr E’s pain was well controlled. On 19 November at 2.42pm, records stated that Mr E was being well managed with syringe driver medications. The dose of oxycodone in the syringe driver was increased that day to reflect the stat dose administrated overnight.

20. On 20 November at 9.14am, the community team received a referral from the night nursing team, who were unable to attend due to limited capacity. Mr E was documented as being in pain and agitated. He was administered 5mg of oxynorm (opioid painkiller) and 2.5mg of midazolam (short-acting benzodiazepine to manage severe agitation).

21. On 21 November, at 11.30am, Mrs H informed the community nurse that her husband had been in pain during the early hours. She contacted the night nursing team, who administered a stat of oxycodone 5mg. The dose could not be increased further because Mr E had reached the maximum daily dose of 20mg, in line with the community medication records. At 5.48pm the community nurse made an urgent referral as Mr E required stat medication. On 22 November, at 8.48am the stat medication was administrated.

22. The records from the Hospice and the community district nurse indicate that at times Mr E experienced periods of comfort and at other times episodes of pain, which the doctor and community district nurse managed promptly in response to his clinical needs.

23. Overall, the records indicate that Mr E’s pain management was consistent with NICE NG31, which recommends regular assessment, anticipatory prescribing, prompt treatment of breakthrough pain, and escalation when pain is not controlled. The evidence shows that the Hospice actively managed Mr E’s pain until the day of his death. We therefore see no indication of a failing on this complaint point.

Checking the availability of medication before prescribing

24. On 19 November, Mrs H could not collect the prescribed medication octreotide (medication to treat pancreatic tumours) from the hospital pharmacy as the medication was not available at the time of attendance. Mrs H believes the prescribing doctor should have checked the availability of the medication before issuing the prescription.

25. The GMC guidance on prescribing medication makes no mention of ensuring that the relevant drugs are available. Our adviser confirmed there is no national guidance or local policy that requires a doctor to confirm pharmacy stock availability prior to prescribing.

26. In its complaint response, the Hospice accepted that it would have been preferable to check availability in advance and apologised to Mrs H for the distress caused. In accordance with our principles of good administration, the Hospice acknowledged the issue, provided an explanation and acted promptly to put matters right. The Hospice sourced the required medication, which was made available for Mrs H to collect at 5pm on the same day.

27. As a result of this complaint, the Hospice has made arrangements to reduce the risk of delays in accessing prescribed medication. This includes an embedded electronic prescribing, to improve accuracy and timeliness of prescription and have established strong working links with a named pharmacist within the acute Trust, who works closely with the Hospice team.

28. We recognise that Mrs H experienced frustration and upset because of the initial unavailability of the medication. However, the evidence shows that the matter was resolved quickly and effectively and did not result in a prolonged delay or a failure in Mr E’s pain management. As the Hospice took appropriate remedial action and have implemented service improvement, we consider there is no unremedied injustice arising from this complaint point.

Communication

29. Mrs H complains that there was no communication from the Hospice around her husband’s medication.

30. The GMC guidance paragraph 37 states that doctors must be considerate and compassionate to those close to a patient and be sensitive and responsible in giving them support and information.

31. On review of the medical records, at 10.42am Mrs H called the Hospice to advise that she could not collect her husband’s medication from the hospital pharmacy. The Hospice staff responded by working with the community district nurse to source the required medication. At 2.42pm, the district nurse made a home visit and updated Mrs H on the status of the medication and the actions being taken.

32. Although the community district nurse provided the update, this communication formed part of the coordinated response by professionals involved in Mr E’s care. The Hospice was actively engaged in resolving the issue and ensured that Mrs H received information through the care team.

33. While Mrs H would have preferred direct communication from the Hospice, the evidence shows she was kept updated through the appropriate clinical channels. We therefore see no indication of maladministration on this complaint point.

Complaint handling

34. Mrs H complains that the Hospice did not adhere to its own complaint procedure, did not keep her updated and had not established a clear process for making a complaint. She also raised concerns about poor follow up, correspondence being addressed to her using an incorrect name and being incorrectly signposted to the wrong panel member to progress her complaint.

35. Our NHS complaints standards say we expect organisations to ‘support and encourage staff to be open and honest when things have gone wrong.’ It is also important ‘staff recognise the need to be accountable for their actions.’ Finally, our standards say when an organisation investigates a complaint it should ‘explain why things went wrong and identify suitable ways to put things right for people. Staff should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.’

36. The Hospice acknowledged shortcomings in its complaint handling. It apologised for correspondence being incorrectly addressed and recognised an administrative failure in calls not being transferred to the director of nursing and care as intended. The Hospice explained that Mrs H’s complaint was handwritten and difficult to read, and that the executive personal assistant who does not have access to medical records, addressed correspondence using the name they believed had been written, without the ability to cross-reference against clinical records.

37. The Hospice accepted that Mrs H was incorrectly signposted when attempting to progress her complaint. In response, it has put arrangements in place to ensure that calls relating to complaints are transferred correctly and in a timely manner to the appropriate senior staff.

38. In addition, the Hospice has reviewed and updated its complaints policy and patient information leaflet, which was approved by the Quality and Governance Committee attended by clinical trustees and the Chief Executive. A new process has been introduced whereby all complaint correspondence is managed centrally by the executive personal assistant, with a holding letter issued at the outset clearly outlining the complaints policy and process before the complaint is allocated to the relevant director for investigation.

39. We have seen the Hospice acknowledged administrative errors, apologised, explained what went wrong and implemented service improvements to prevent recurrence. These actions align with the NHS complaint standards. We therefore see no unremedied injustice in relation to complaint handling.

Conclusion

40. We acknowledge the distress Mrs H suffered watching her husband in pain at the end of his life. The Hospice followed the guidance and responded promptly to Mr E’s needs to manage his pain. The Hospice resolved the issue in getting Mr E his medication quickly and have improved services to prevent a recurrence. The Hospice fell short on communication and complaint handling, but we have seen it apologised and implemented service improvements.

1. We have carefully considered Mrs H’s complaint about Pilgrims Hospice (the Hospice) and the care and treatment it provided her husband Mr E. We are sorry to learn of Mrs H’s loss and the distress and upset of going through the complaint process during a difficult time.

2. Having considered the evidence, we have seen Mr E’s pain management up until his sad death was managed in line with the guidance. The Hospice kept the community district nurse informed on the status of Mrs H’s husband’s medication who in turn updated Mrs H. We consider this to be reasonable. There was a shortcoming which the Hospice have acknowledged around availability of medication and complaint handling for which it has made service improvements in line with our principles.

3. We have explained the reasons for our decision below.