Dorset Healthcare University NHS Foundation Trust

3. Mrs E complains about the end-of-life care and treatment Mr E received during the day he died. She says despite contacting the district nursing liaison because she was concerned about her husband’s condition, the Trust failed to attend her property before he died.

4. Mrs E says the Trust’s actions meant Mr E did not receive appropriate pain relief and therefore suffered a prolonged painful death.

5. She also says that her and her daughter were left to care for Mr E on their own, which was distressing.

6. In bringing this complaint to us Mrs E seeks service improvements, a sincere apology and financial compensation.

7. Having received a terminal cancer diagnosis, Mr E wanted to have his last moments at home. The Trust arranged for this to happen. It scheduled district nurse visits to his home as part of his end-of-life care. The Trust told his family to call its community team if they needed further help or support.

8. The Trust placed Mr E on a high risk of death list. When Mrs E contacted the community team regarding concerns about Mr E’s condition at 8.30am on the day he died, staff visited five hours later.

9. Mr E died before the Trust’s staff attended his house.

13. The Trust diagnosed Mr E with terminal lung cancer in early 2025. Having spent some time as an inpatient with the Trust, in March Mr E decided he would like to spend his remaining days at home.

14. The Trust referred Mr E to the integrated community team and placed him on a high risk of death list. Staff prescribed just in case (JIC) medication, and a drug chart (to enable nurse administration) was documented as being available in his home.

15. Later in March, the Trust created a wellbeing plan. It outlined that district nurses were to visit Mr E at home once a week to support with palliative care and twice a week to redress the wounds on his legs. Staff then discharged him home.

16. When Mr E was at home, Mrs E contacted the Trust at 8.30am on the day he died. She was concerned about Mr E’s state. The district nursing sister called Mrs E at 8.52am and Mr E’s visit was triaged. The Trust informed Mrs E nurses would visit other patients requiring insulin first, and then they would visit Mr E. In its complaint process, the Trust accepted Mr E’s visit would have been at 11.30am, two hours and thirty minutes after the telephone triage.

17. Mr E sadly died at 1.30pm, and before the districted nurses arrived. A second telephone conversation took place between Mrs E and the Trust before the nurse arrived at 2.30pm, to verify Mr E’s death.

18. Section 1.9.2 in NICE Guideline 142 says nurses should provide symptom management for adults approaching the end of their life. Given the Trust’s nurses were not present for Mr E’s final hours, it is clear they were unable to provide Mr E with JIC medication to manage any pain symptoms.

19. Our adviser said nurses could have provided pain relief, if they visited Mr E before he died and assessed he was in pain during these assessments. Therefore, at the point nurses visited Mr E, we would have expected nurses to assess his pain. Based on the instructions from NICE Guideline 142, they should have given him pain relief if their assessment indicated this need.

20. We appreciate the Trust explained reasons it did not or could not visit Mr E in its response to Mrs E’s complaint. Therefore, we considered these factors, how it triaged Mr E, when nurses should have attended, and whether they delayed seeing him.

21. Our adviser said the initial triage of Mr E was appropriate, in accordance with the Trust’s Response Policy. This outlines nurses should attend within two to four hours for urgent call outs, including symptom control, which Mr E needed. We saw the Trust’s initial plan for one of its nurses to attend at 11.30am was within this period.

22. The Two-hour Response Standard (section 6.2) says staff should use their professional judgment to decide if a person needs a response within two hours, or more than two hours. This should take into consideration co-morbidities and the complexity of a person’s needs.

23. Our adviser did not consider the two-hour response time applied, as they felt Mrs E’s triage call did not indicate this. It was our adviser’s view the community nurse should have attended Mr E’s house around 11.30am, following the insulin calls they needed to make with other patients, as per the initial triage.

24. After the nurse made these insulin calls, the Trust acknowledged they decided to wait longer for a second colleague to come with them. In its response to Mrs E’s complaint, it acknowledged this was not the standard of care it aimed for. This seems to explain the nurse not visiting Mr E within the Trust’s timeframes and before he died.

25. On this basis, we saw indications of a failing. This meant we went on to consider the impact this had, including the impacts Mrs E described in paragraphs four and five, and whether the Trust took the action it should address this.

26. As nurses were not present for Mr E’s end of life, we are unable to say on the balance of probabilities whether the nurses would have assessed Mr E as being in pain and prescribed him pain relief. We note the Trust’s record of Mrs E’s phone call show staff asked her if Mr E was in pain. She said she felt he was ‘fading’, but not in any distress at the time. So, they may not have administered further pain relief had they attended.

27. However, we consider this to be a missed opportunity in the Trust’s care and treatment to consider and potentially provide pain relief before Mr E died.

28. Mrs E claims that she and her daughter experienced emotional distress. We consider these events did cause a level of distress and upset, given they were left to care for Mr E on their own at such an already emotionally challenging time.

29. She also says Mr E experienced unnecessary pain at the end of his life, which pain medication given by nurses during a visit may have prevented. As we explained in paragraph 26, it is not possible to understand what treatment, if any, the district nurses may have administered following an assessment of Mr E’s pain.

30. This means we cannot robustly conclude whether he would have received pain medication, and whether this would have prevented him experiencing any avoidable pain. We appreciate this will leave Mrs E with uncertainty about what difference a nurse’s visit may have made.

31. We appreciate how distressing this experience must have been for Mrs E, and how difficult it will be that we cannot conclude what difference a visit from the Trust’s nurses may have made.

32. In bringing this complaint to us, Mrs E seeks financial remedy, service improvements and a more sincere apology that fully reflects the impact of the Trust’s actions.

33. We recognise the Trust has already offered an apology and indicated a willingness to implement learning from its care of Mr E. We have requested a further, more meaningful apology, which addresses the injustice we have seen, and an action plan documenting the service improvements it will implement. Our Principles for Remedy say these are appropriate actions, and the Trust has agreed to do these things to resolve the case.

34. We have similarly requested financial remedy, in light of what we saw. Our Principles for Remedy say, ‘where maladministration or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complaint to the position they would have been in otherwise. If that is not possible, the remedy should compensate them appropriately’.

35. We looked at our Guidance on Financial Remedy. We would put the impact of Mrs E’s complaint at level two on our Severity of Injustice (SOI) scale. Within this, payments range from £120 to £550.

36. This guidance says, where the impact of a death was exacerbated by poor care, but there is no evidence the poor care caused the death, a case falls into level two when such care causes distress to family members around the time of the person’s death. We can see this applies in Mrs E’s complaint, during a period of a few hours on the day Mr E died.

37. To decide on a level of financial remedy, alongside our SOI scale, we also review similar cases where the person experienced similar injustice. Following this review, we think a financial payment of £425 is appropriate.

38. We contacted the Trust about paying Mrs E this financial remedy. It agreed to do so, in addition to writing to her to apologise about the impact we identified. It also agreed to compose an action plan on what it would do to prevent the issues we saw in Mr E’s care happening again.

39. As the Trust agreed to provide all the outcomes Mrs E wanted through us investigating, we were able to resolve her complaint. On this basis, we decided not to consider her complaint further. We hope we have clearly explained the reasons for our decision.

40. We recognise the action the Trust has agreed to take will not change the experience Mrs E and her family had. We hope the remedies the Trust has agreed to provide will help bring her some closure, and the Trust’s action plan gives her assurance about it learning lessons from what happened in Mr E’s care.

1. We have carefully considered Mrs E’s complaint about the Trust. We are sorry to hear about the very difficult time Mrs E has clearly experienced. We would like to thank Mrs E for sharing the details of her concerns, as we know this may have been distressing for her.

2. Having considered Mrs E’s complaint, we have seen the Trust failed to follow national guidance when providing end of life care for her late husband (Mr E). The Trust has recognised its errors and has agreed to take steps to put this right. On the basis we have agreed what we consider a suitable resolution; we have decided not to consider Mrs E’s complaint further.