Maidstone and Tunbridge Wells NHS Trust

3. Miss D complains the Trust prevented her partner, Mr G, from going home earlier during his admission in March 2024. She also says it forced him to take Oramorph and inserted a catheter against his will.

4. Miss D says her partner’s last days on earth were a living hell and believes it likely shortened his life. She explains he wanted to go home, see the outdoors and familiar surroundings. She says the Oramorph (strong pain relief) made him drowsy, and he wanted to be alert as much as possible. She explains he was not talking much by the end of his life, and he was dying with his own thoughts. She believes it denied him the right to have a decent dignified death and says he just wanted to be outdoors to not feel trapped. Miss D wants service improvements and a financial remedy.

5. Mr G had a history of diabetes and pancreatic cancer which had spread to his liver and lungs. His oncology team referred him to the Trust’s emergency department (ED), in late February, as his blood sugars were high. The Trust admitted him on the same day. It discharged him to a hospice in mid-March. Mr G sadly died the day after it discharged him.

8. Miss D says the Trust prevented her partner, Mr G, from going home earlier during his admission in March 2024. She is also concerned it forced him to have Oramorph and inserted a catheter against his will during the same admission. We do not underestimate the impact Mr G’s death has had on Miss D, and we are grateful for the time she has taken to explain her complaint to us.

9. GMC says all patients have the right to be involved in decisions about their treatment and care.

10. We reviewed Mr G’s records to establish what happened during his admission. Miss D is clear the Trust prevented him from leaving hospital. The records show the Trust confirmed he was medically fit for discharge in early March. Mr G agreed for the Trust to arrange a package of care to be put in place support him when he was at home. A package of care is a personalised combination of health and support services designed to meet an individual's specific daily living and medical needs.

11. The Trust explained it could not discharge Mr G until the package of care was active. Miss D told staff she would be with Mr G at home. We have seen a record to show staff informed Mr G and Miss D if they did not want to wait for the package of care to be activated, they could complete a self-discharge form if they wished to do so.

12. A few days later the Trust noted Mr G fell over the weekend, and he had a new requirement for oxygen. It planned to carry out further investigations to confirm the cause of his new symptoms. There is evidence to show the Trust asked Mr G if he wanted to go ahead with its planned investigations and remain an inpatient. The Trust gave Mr G some time to think about it and the records show later, on the same day, he agreed to stay in hospital and have the suggested medical interventions.

13. The Trust noted a couple of days later Mr G asked for paracetamol due to pain in his right side. It explained he was not due another dose of paracetamol and it offered him Oramorph. The record shows Mr G insisted he wanted Oramorph, despite Miss D’s concerns that it made him drowsy.

14. The day after we can see the Trust carried out scan of Mr G’s bladder which showed urinary retention (inability to fully or partially empty the bladder, resulting in urine staying in the body even when you try to urinate). The records show the Trust inserted a catheter, a thin tube used to drain the retained urine in Mr G’s bladder.

15. The Trust’s palliative care team reviewed Mr G later the same day and noted he had a catheter in place. He did not report any concerns with the catheter at this time. The team noted he was calm and not in any distress. There is no evidence to suggest Mr G did not agree to have the catheter inserted. Mr G explained his right-side pain was responding to Oramorph and he did not mind that it made him drowsy.

16. The following day there is an entry in Mr G’s records to show Miss D told staff he was in pain and he wanted Oramorph. The Trust provided him with Oramorph, and it removed Mr G’s catheter at his request.

17. The Trust’s palliative care team reviewed him the day after, and they agreed to look into a fast-track discharge after the weekend. This is an accelerated hospital discharge process for individuals with rapidly deteriorating conditions who are nearing the end of their life.

18. The Trust discussed discharge options with Mr G after the weekend. We can see he initially said he wanted to go home. However, later the same day he said he would prefer to go to a hospice first. The Trust arranged a bed at a hospice for him and discharged him to it the following day.

19. Based on the information we have seen, there does not appear to be any evidence which suggests the Trust prevented Mr G from going home earlier. We recognise from what Miss D told us they were both disappointed when the Trust advised them against discharge.

20. We can see it explained he could complete a self-discharge form. We cannot see evidence Mr G wanted to do this. The Trust asked Mr G what he wanted and it appears he chose to remain at the Trust for further investigations and treatment. There is also evidence staff discussed his discharge options with him and discharged him to a hospice based on his preference. This appears to be line with GMC guidelines which says doctors should involve patients in decisions about their care and treatment.

21. The records also indicate Mr G wanted the Trust to provide him with Oramorph on several occasions to treat his pain despite the fact it made him drowsy. We also cannot see Mr G raised any concerns about the Trust inserting a catheter at the time and it removed it when he requested it to. The evidence we have seen does not suggest the Trust forced Mr G to have Oramorph or inserted a catheter against his will. It appears the Trust also followed GMC guidelines here to involve him in decisions about his treatment and care.

22. We have carefully considered Miss D’s concerns. It is clear from what she has told us that she believes Mr G felt trapped during his admission and we recognise how difficult this must be for her to think about. We accept that Miss D’s recollection of events differs from what is written in Mr G’s medical records.

23. Where we have a contemporaneous written record, we cannot simply dismiss it unless we have good reason to doubt its accuracy. We do not doubt the sincerity of Miss D’s recollections. However, those recollections alone do not provide grounds on which we could challenge the records.

24. We are sorry to hear Miss D feels the Trust did take into account what Mr G wanted. We have carefully reviewed Mr G records. We are satisfied the Trust involved him in decisions about his own care and treatment and he agreed to remain at the Trust. We can see it gave him information about how to self-discharge and there is no evidence to suggest it prevented him from leaving earlier, during his admission.

25. It also appears Mr G did not raise any concerns when it inserted a catheter, and he asked the Trust to provide him with Oramorph. As such we cannot say the Trust forced him to do either.

26. We do not underestimate the impact Mr G’s sad death has had on Miss D. We hope this statement provides her with reassurance that we did not find indications the Trust got anything wrong and clearly explains our decision not to consider her complaint further.

1. We have carefully considered Miss D’s complaint about Maidstone and Tunbridge Wells NHS Trust (the Trust). We are sorry to hear about Mr G’s sad death, and we would like to extend our sincere condolences to Miss D.

2. We have looked at the evidence Miss D and the Trust provided. Based on the information we have seen, there is no indication the Trust prevented Mr G from leaving hospital. It also appears the Trust followed relevant guidelines when it involved Mr G in decisions about his own care and treatment. We did not see any evidence something went wrong. Therefore, we will not be taking further action on this complaint. We will explain our decision in more detail below.