Hampshire and Isle of Wight Healthcare NHS Foundation Trust

3. Mrs C complains about the care provided to her husband, Mr C, at home by Hampshire and Isle of Wight Healthcare NHS Foundation Trust (the Trust), in the days prior to his death on 5 March 2025.

4. Mrs C complains that the Trust:

• did not admit Mr C to hospital when it was draining blood out of his abdomen drain • did not use the medication in Mr C’s ‘just in case’ medicine pack that would have helped him with the mucus he was coughing up • did not provide Mr C with a higher dose of morphine, despite the community nursing team having it available to them.

5. Mrs C says that as a result of this Mr C died in agony at home. Mrs C explained that Mr C wanted to die in a hospice, however, was not well enough to go.

6. Mrs C seeks:

• the Trust to be aware that it made mistakes in Mr C’s case, and to take learning from it • a financial remedy.

7. Mr C had cancer and was receiving support for this through the Trust community nursing team at home.

8. On 28 February 2025 Mr C attended hospital to have a drain fitted to help with the pain in his abdomen. Following this procedure, Mr C had over 7 litres of liquid drained from his abdomen. Mr C was then discharged home with some drain packs and spare dressings. He was advised that the district nurses would attend to change his dressing in two days’ time.

9. On 1 March 2025 a nurse visited Mr C at home to look at his dressing. They did not change the dressing or his drain but took his blood pressure, temperature, and weighed him. Mrs C recounts that Mr C was in a lot of pain throughout this day and into the night.

10. On 2 March 2025 a nurse again visited Mr C to look at this dressing. Again, they did not change Mr C’s dressing or drain but took his blood pressure and temperature. The nurse explained that they were concerned as Mr C’s blood pressure was quite low. The nurse contacted a doctor to advise them of this.

11. On 3 March 2025 a nurse visited Mr C to drain his abdomen. The fluid that was drained had a red tone to it. The nurse called a doctor and told them that they were worried about the colour of the fluid that was being drained. The doctor advised them to review it the next day and that the drain may have just been rubbing on something and causing it to bleed. The nurse gave Mr C an anti-sickness injection following this.

12. On 4 March 2025 two nurses attended to see Mr C. They drained 100ml of blood stained fluid from Mr C’s abdomen. As they were doing the drain Mr C started coughing and so they decided to stop draining. They arranged for another nurse to come out and take Mr C’s blood and a urine sample. Mrs C told us that Mr C was very agitated this day, and later that day he decided he wanted to get up out of his chair. Mrs C said that she tried to hold him up, however he fell to the floor. Mrs C called an ambulance and her daughters to attend to help her.

13. Paramedics then attended and took Mr C’s blood pressure. It was very low. They discussed giving Mr C fluids however said that his veins were not good and that this would need to be done through his feet. It was decided that this would be putting Mr C through unnecessary pain and distress and so he was not given any fluids. It was discussed whether Mr C should be transferred to hospice, however the paramedics advised that he was not well enough to make the journey there.

14. While Mr C was on the floor, he began retching and was bringing up a clear mucus. The paramedic advised Mrs C that they could give him some medicine to support with this and gave him some from his ‘just in case’ medicine pack.

15. The paramedic team, along with Mrs C and her daughters, got Mr C back into his bed. Mrs C said that Mr C was in agony throughout this, despite being on large doses of morphine.

16. Sadly, Mr C then died at home in the early morning of 5 March 2025.

20. 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.

Failure to admit Mr C to hospital after draining blood from his abdomen

21. Mrs C told us that on 3 March 2025 a nurse visited Mr C at home to drain fluid from his abdomen. Mrs C said that the fluid that was drained was red, and the nurse told her that the drain was likely just rubbing on something and causing it to bleed.

22. Mrs C told us that a nurse visited again on 4 March 2025 to drain Mr C’s abdomen. She explained that blood was drained and that the nursing team had to stop as Mr C was coughing. She said that they arranged for Mr C to have a blood test.

23. Mrs C feels that Mr C should have been admitted to hospital when such a large amount of blood was drained from his abdomen. Mrs C feels that if Mr C was in hospital he could have been supported with this and have been in less pain.

24. In its complaint response on 1 April 2025 the Trust did not specifically mention the draining of blood from Mr C’s abdomen, however it has acknowledged that Mr C’s symptoms were ‘particularly challenging’ in the final days of his life and it was unable to drain too much fluid from his abdomen due to his low blood pressure.

25. Mr C’s medical records show that on 3 March 2025 he was visited at home by a community nurse. The notes explain that Mr C’s blood pressure was low, and so they planned to drain his abdomen slowly so that they could monitor him.

26. The notes show that during this session, the nurse managed to drain 500ml of fluid from his abdomen. It is noted as being ‘blood stained’. The notes explain that the nurse contacted a nurse practitioner for advice who told them to arrange a blood test.

27. Mr C’s medical records show that on 4 March 2025 the community nurse visited him again to drain his abdomen. It is noted that they were only able to drain around 100ml of ‘blood tinged’ fluid, as Mr C started to feel unwell.

28. The records show that the nurse then contacted oncology to discuss Mr C’s current symptoms, and it advised them to await the results of the blood test from the previous day. It also told the nurse that Mr C had an appointment with it on 5 March 2025 and it will review him then. Sadly, Mr C died before he was able to attend this appointment.

29. The NMC code explains that nurses should respect the skills, expertise and contributions of their colleagues, referring matters to them when appropriate.

30. Our nursing adviser said that this means that community nurses have the responsibility to seek further advice from colleagues with more expertise than them, if they identify a potential concern with a patient’s condition that is outside their scope of practice.

31. Mr C’s records show that on both 3 and 4 March 2025, the community nurse contacted oncology to advise them of the blood stained fluid being drained from Mr C’s abdomen and asked what the next steps should be in Mr C’s care.

32. In line with the NMC Code, the nurses correctly escalated their concerns about the fluid being drained from Mr C’s abdomen to oncology and followed their recommendations in Mr C’s care.

33. We discussed with our general physician adviser if oncology were correct not to suggest to the community nursing team that Mr C needed to be admitted to hospital. Our general physician adviser explained to us that as Mr C had capacity, his wishes needed to be respected. Throughout Mr C’s medical records, it is reported that he had capacity, and he had made it clear that he did not want to attend hospital and would rather be at home, or in a hospice.

34. The end-of-life care guidance explains that healthcare professionals caring for adults at the end of life need to take into consideration the person’s current mental capacity to participate in decision making on their end-of-life care. It then says that as part of this, the patient’s current goals and wishes need to be taken into account.

35. Throughout Mr C’s records it is reported that he had capacity and made it clear that he did not want to attend hospital, and would rather be at home, or in a hospice. We can see that it was suggested that Mr C might be moved to a hospice, however, he was too unwell to travel there.

36. In line with the guidance on end-of-life care, we consider the Trust respected Mr C’s wishes to not be admitted to hospital.

37. We understand that it will have been difficult for Mrs C to see her husband suffering and feel that the nurses should have done more to support Mr C with the blood that was being drained from his abdomen and admit him to hospital.

38. We consider the nurses acted in line with the NMC Code in escalating their concerns to oncology and confirming with it that Mr C had an appointment to follow this up.

39. We recognise that it will have been distressing for Mrs C to feel that her husband needed to be admitted to hospital. We consider that the Trust were correct to not make this decision on Mr C’s behalf, as he had capacity, and had repeatedly expressed that he did not want to be admitted. We will therefore not consider this complaint further.

Use of ‘just in case’ medicine pack

40. Mrs C told us that when Mr C fell on 4 March 2025 he was coughing up mucus. The paramedics who had attended to help Mr C told Mrs C that he had some medicine in his ‘just in case’ medicine pack that they have kept at home, that could help Mr C with this. Mrs C explained that they had been told previously that there was nothing that could be done to help Mr C with his mucus.

41. Mrs C told us that Mr C had been having difficulties with mucus for months at this point. She feels that had the Trust used the medicine in his ‘just in case’ pack sooner, it would have made Mr C more comfortable.

42. Mr C’s medical records show that he was prescribed hyoscine butylbromide on 28 January 2025 and that this was available to be administered to Mr C as and when needed from 13 February 2025. Hyoscine butylbromide is a medication used to relax the digestive tract and bile system and can help to reduce distressing oral and chest secretions.

43. The records also show that prior to Mr C being given the medication by the paramedic on 4 March 2025, he was administered hyoscine butylbromide on 13 and 20 February 2025 and again on 3 March 2025.

44. The nursing standards explains that nurses should administer medications in accordance with a prescription and ‘patient specific direction’.

45. Our nursing adviser explained that this means that community nurses should only administer medications for the purpose that they are prescribed for. It would therefore be the responsibility of the community nurses to make the decision on if or when Mr C needed the hyoscine butylbromide administered.

46. We can see from the records that Mr C was administered hyoscine butylbromide on four different occasions between February and March 2025, and one of these occasions was on the day before the paramedics attended. Although we cannot say for certain if there were any other occasions when Mr C needed this medication, and was not provided with it, we can see that he was provided it when the nurses felt necessary.

47. Therefore, we consider that in line with the nursing standards, the nursing team correctly administered Mr C with the hyoscine butylbromide medication on an as and when basis.

48. We understand why it will have been distressing for Mrs C to feel that there was some medication that was prescribed to Mr C that was not being administered to him. We have seen no indications that Mr C was not given his hyoscine butylbromide medication to support him with his mucus prior to 4 March 2025. We will therefore not consider this complaint further.

Administration of morphine

49. Mrs C told us that Mr C was ‘in agony’ in the final days of his life. She explained that he was in so much pain that he asked if he could be put into a coma. We can recognise that this will have been extremely distressing for Mrs C and her daughters to witness.

50. Mrs C explained that when she asked the nurse if Mr C could have more pain relief, she was told that there was no more that could be given to him. Mrs C told us that Mr C had been prescribed a higher dose of morphine by his GP, and he therefore should have been administered this. She feels that this would have avoided some of the pain that he experienced.

51. In its complaint response on 1 April 2025 the Trust say that the clinicians visiting Mr C used their laptops to access the most up-to-date prescription list for him and administered his morphine accordingly.

52. Mr C’s medical records show that he was prescribed 5-10mg of morphine that could be taken hourly.

53. On 3 March 2025, Mr C’s records show that he told the nursing team that the morphine was working well to manage his pain, however, was making him feel ‘bad’. Mr C explained to the nurse that it made him feel ‘muddled’ and as if he was ‘hallucinating’.

54. The records show that on 4 March 2025, Mr C was administered four different doses of morphine. These were 2.5mg at around 1:30pm, 2.5mg at around 3pm, 5mg at 6:40pm and 5mg at 9pm. Mr C also had a syringe driver commenced with 40g of morphine, amongst other medications, at around 6pm.

55. In line with Mr C’s prescription, he could have been given up to 10mg of morphine on each occasion that he was administered it on 4 March 2025. The maximum amount that Mr C was given on any occasion was 5mg.

56. Our nursing adviser explained to us that it is important for nurses to consider the potential side effects of higher doses of morphine on a case-by-case basis. They explained that as Mr C was at the end-of-life, if higher doses of morphine were given there would have been a concern about causing uncomfortable or distressing side effects such as vomiting, vertigo and hallucinations. They explained that in Mr C’s case, he had very low blood pressure and high doses of morphine can make this worse.

57. The guidance on morphine explains these side effects. It says that morphine can cause many common negative side effects, including vomiting, vertigo, hallucinations and low blood pressure amongst others.

58. The nursing standards explain that nurses should demonstrate knowledge of pharmacology, and the ability to recognise the effects of medicines, allergies, drug sensitivities, and side effects.

59. In Mr C’s case, the nurses had to weight up the pain Mr C was in against Mr C’s previously reported side effects, his low blood pressure, and the potential of higher doses of morphine to make these worse.

60. Our nursing adviser said if the nurses had provided higher doses, rather than easing his pain, this could have made this worse by causing uncomfortable side effects.

61. We consider that it was appropriate for the nurses not to administer Mr C a higher dose of morphine, as in line with the nursing standards, they needed to recognise the side effects and adverse reactions, such as those listed in the guidance on morphine.

62. As Mr C had already been given multiple doses of morphine, and had been started on a syringe driver, our nursing adviser said it was appropriate to wait to see the effects that these had on Mr C before they administered a higher dose. Sadly, Mr C died shortly after this.

63. In line with the guidance on morphine, the nursing standards, and considering the information provided to us by our nursing adviser, we consider it was appropriate that the Trust did not offer Mr C any more morphine, despite his prescription saying that this was available to him. Therefore, we will not consider this complaint further.

64. We understand that it will have been extremely difficult for Mrs C and her daughters to witness Mr C’s death. We recognise their concerns about the treatment that Mr C received. We would like to thank Mrs C for taking the time to bring this complaint to us. We hope that this statement offers her and her daughters some closure.

1. We would like to thank Mrs C for taking the time to bring her complaint to us. We recognise that it will have been extremely difficult for Mrs C and her children to witness Mr C’s death and we would like to offer our condolences to them.

2. We have carefully considered Mrs C’s complaint about Hampshire and Isle of Wight Healthcare NHS Foundation Trust (the Trust), we have seen no indications that anything went wrong in Mr C’s care. Therefore, we will not consider this complaint further.