Salisbury NHS Foundation Trust

7. Mr I complains about aspects of the care and treatment Salisbury NHS Foundation Trust (the Trust) provided to his wife, Mrs I, in the last week of her life in December 2024. He specifically complains staff:

• on the Acute Medical Unit (AMU) incorrectly kept Mrs I on nil by mouth (NBM) • did not provide adequate care to Mrs I in relation to swollen legs • on the Acute Stroke Ward (ASW) left Mrs I in a state of undress, without privacy • did not follow the agreed end of life pathway action plan • were slow to provide pain relief despite requests from clinical staff to increase this as necessary.

8. Mr I says that the substandard treatment the Trust provided to Mrs I led to her end-of-life care being more difficult and distressing than it already would have been. He considers she suffered unnecessary pain due to the delays and issues with pain medication administration.

9. Mr I is seeking service improvements from the Trust across all areas of his complaint.

10. In December 2024, Mrs I attended the emergency department (ED) with increased shortness of breath, a new oxygen requirement and visual loss in her left eye.

11. The next day the Trust transferred Mrs I from the ED to the AMU.

12. The Trust arranged for her to have an abdominal scan. It identified her as NMB.

13. Two days later, Mrs I had a stroke. The Trust transferred Mrs I to the ASW.

14. The Trust determined, in agreement with the family, to put Mrs I on end-of-life care.

15. The Trust moved Mrs I to a side room. She sadly died the next day.

Nil-by-mouth (NBM)

21. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have not found any indication that this issue had a significant impact on Mrs I. We understand it was concerning for Mr I at the time.

22. Mr I said staff informed him Mrs I needed a computed tomography (CT) scan so she was identified as NBM (meaning she was not to eat, drink or take medication orally). A CT scan is a medical imaging test that uses X-rays and a computer to create detailed images of the inside of the body.

23. Following the CT scan, Mr I said staff failed to remove the NBM notice from her bed. This meant staff did not offer her food until late in the afternoon. He said therefore she was without food from after breakfast time.

24. The Trust explained it was necessary for Mrs I to be NBM prior to the scan. This was to ensure an enlarged stomach did not obscure the radiographer’s view of the anatomy that they needed to assess.

25. The Trust said staff should have removed the NBM sign on her return to the ward and apologised for not doing so. It noted when staff later offered Mrs I food and drink that day, she declined and was given anti-sickness medication.

26. NHS information about CT scans indicates a patient may need to be NBM prior to a CT scan. It says staff will discuss this with the patient, which appears to have been the case in this situation.

27. The Trust’s leaflet about CT scans clearly indicates that following the scan, the patient can eat and drink.

28. We can see from the clinical records, the Trust determined Mrs I should undergo an abdominal, ultrasound scan. This was completed at 2.32pm. There is nothing in the records to say that Mrs I could not eat after the scan. The evidence we have seen does not show when she was then offered food.

29. Our adviser said in line with NHS guidance NBM is a common requirement to improve the image quality. In line with the Trust’s own CT scan leaflet, they said here is generally no restrictions on eating after the CT scan.

30. We consider it was correct for Mrs I to be place on NBM initially. We think staff should have then removed the NBM sign when they had completed the CT scan. We understand why Mr I would have been worried for Mrs I when she had not been offered food for some time.

31. We know when staff did offer Mrs I food and drink she declined and was given anti-sickness medication. This suggests she would not have accepted food during the time the NBM sign remained in place. We cannot say this concern impacted on Mrs I’s health.

32. We do not intend to minimise this part of Mr I’s complaint and understand it is one part of his wider concerns about the Trust and the care it provides. The Ombudsman is a limited resource and cannot investigate every complaint we receive. We need to focus on the more serious complaints that people bring to us, where they may have faced a big impact. Based on this, we will not consider this part of Mr I’s complaint further.

Leg care and treatment

33. Mr I said he was extremely concerned about Mrs I’s swollen legs. He said they were causing her considerable pain and discomfort. He said he raised his concerns several times and a nurse told him they would arrange an airflow mattress to make her more comfortable. An airflow mattress is a type of specialist mattress used to prevent and treat pressure sores.

34. Mr I said he asked for this throughout the afternoon, but it did not arrive. He said it took him to make a complaint about all his concerns before the mattress then arrived.

35. The Trust said Mrs I had swollen legs due to heart failure which can cause discomfort. It said during her time on AMU her pain score increased and staff administer intravenous pain relief. It apologised for the delay in providing an airflow mattress and attributed the delay to staff issues.

36. NHS information around swollen ankles, feet and legs says this is caused by a build-up of fluid in these areas, called oedema. It identifies the causes of oedema including problems with your kidney, liver or heart. It advises an individual should raise their legs, or the swollen area, onto a chair or pillows to ease the problem.

37. We acknowledged we have taken this information from the NHS website regarding swollen ankles was reviewed after the date of the complaint. We can see the website is reviewed every three years and we believe the information cited on was relevant at the time of the complaint, in 2024.

38. We can see little mention of leg swelling within the records. However, we have seen a note which says Mrs I was sat out of bed, ‘made comfortable, and provided with a footstool to assist with swelling in her legs’.

39. Our adviser said this intervention was appropriate and consistent with recognised clinical management of lower limb oedema. They explained elevation of swollen lower limbs is a recognised supportive measure to promote comfort and to assist with reducing the effects of swelling.

40. We know the staff moved Mrs I to an airflow mattress. This is documented in the records. We understand Mr I complains that this took some time and only happened after he complained.

41. Of relevance, our adviser told us an airflow mattress is usually used to address pressure area care and skin protection, rather than for oedema. They said there was no evidence of pressure sores within the records. We can see staff regularly carried out skin care checks.

42. Our adviser said it was likely staff were considering an airflow mattress also as a precautionary measure because they were planning for the likely increased frailty and lack of mobility.

43. We are sorry Mr I had to repeatedly ask for the airflow mattress. We consider the staff provided the appropriate care to Mrs I with regards to leg swelling. We understand Mr I wanted his wife to be as comfortable as possible. We can see staff arranged an airflow mattress without significant delay. We hope Mrs I felt more comfortable when she was using the airflow mattress.

Left undressed without privacy

44. Mr I told us he did not want his wife to be left alone. He said Mrs I was afraid to die by herself. He asked staff to let him know when they had finished carrying out any care and treatment so he could then be with her.

45. He told us he was particularly upset on one occasion when he returned to the ward after staff had been providing treatment to Mrs I. He said he found the curtains to the bay had been left open. Mr I said Mrs I was semi-naked in bed with her catheter and private parts exposed. When he complained, he said staff told him this was to enable them to continue monitoring her.

46. In its complaint response, the Trust acknowledged it was not acceptable for Mrs I to be uncovered on the bed. It apologised for the distress this caused Mr I.

47. Good Medical Practice says, ‘you must treat patients as individuals and respect their dignity and privacy’.

48. We can understand how upsetting this incident was for Mr I. At this time, it appears staff showed an absence of appropriate respect for Mrs I’s dignity and privacy, going against Good Medical Practice.

49. We approached the Trust on this point to ask how it can minimise the risk of this happening again for other patients. It informed us that its priority is to ensure staff maintain patients’ dignity at all times. It said the senior team discuss all complaints and cascade this information to staff so they are aware of concerns raised and can implement actions.

50. We have decided not to take this part of Mr I’s complaint further. This is because the Trust, has apologised, acknowledged the shortfall in care and taken learning.

51. Again, we are not intending to minimise this part of Mr I’s complaint. We monitor themes and trends in complaints. If we receive a lot if complaints about the same issue, this can be flagged to our systemic team. This can lead to a bigger piece of work that engages with the organisation directly to improve service standards.

End of life pathway plan / pain relief medication

52. Mr I said three days after the Trust admitted Mrs I, it was evident her anxiety and pain were increasing. He was so concerned about her deteriorating condition he requested attendance of a doctor to discuss her treatment and the best way forward for her.

53. Following discussion with the doctor and having considered the limited options, Mr I said the family agreed to the end-of-life pathway for Mrs I to make her as comfortable and as pain free as possible.

54. Mr I said he was assured that as soon as treatment was stopped, staff would administer sufficient medication to minimise the pain she was experiencing.

55. However, Mr I said following staff removing the life support mechanisms, Mrs I was in a very distressed state, appeared to be agitated and in great pain. He said staff told him the appropriate medication had been ordered and would be administered as soon as possible. He believed from the conversation with the doctor, that pain relief would have been administered straightaway. He considers the delay resulted in additional unnecessary pain and anxiety for Mrs I.

56. Mr I said thereafter nursing staff ignored the direction from the prescribing doctor that pain relief should be given when required even if this was half hourly. He said this meant Mrs I was left in pain and distress unnecessarily.

57. The Trust said a collective decision was made between the stroke consultant and the family to provide care to keep Mrs I as comfortable as possible.

58. Due to increased concern, Mr I spoke with the palliative care nurse and discussed the use of a syringe driver to administer the medication. The nurse said this would be prescribed for use 24 hours after Mrs I starting the end-of-life pathway.

59. A syringe driver is a small pump that delivers medication through a needle at set intervals, without staff needing to give each dose manually.

60. The Trust said the on-call doctor prescribed anticipatory medication. This is also known as ‘just in case’ medication. It is prescribed in advance, so it is ready if symptoms develop.

61. During the night the nurse on duty prescribed medication to address the pain, agitation and breathlessness that Mrs I was experiencing. They also sought advice from the on-call team regarding the amount of morphine (an extremely strong painkiller) she was permitted to administer to Mrs I at that time.

62. The on-call doctor assessed Mrs I and determined to continue with the medication being given at that time. They discussed the possibility of a syringe drive option.

63. The Trust said the next day the family expressed concern about the level pain Mrs I was experiencing. It contacted the palliative care team to seek advice. The palliative care nurse saw Mrs I and suggested a syringe driver be commenced to manage Mrs I’s ongoing symptoms, rather than continuing medication by injection. The Trust said this commenced promptly.

64. NICE guidelines NG31 says, ‘expert clinicians to assess symptoms frequently and provide medication promptly to maintain comfort. The main standards are: • Prompt assessment and relief of pain • Individualised prescribing and use of anticipatory medicines • Regular reassessment and monitoring • Listening to families concerns • Comfort takes priority • Documentation and clinical reasoning’

65. We can see from the clinical records when the consultant discussed end-of-life care with the family at 6pm in the evening. They explained the role of anticipatory medications. We have seen the end-of-life plan which indicates the aim of plan was to ensure comfort. It details the prescribing of anticipatory medicine.

66. At 12.40am the next day, we can see a record indicating Mr I had expressed his concern that Mrs I’s symptoms were not being controlled as expected. The records show the doctor contacted the palliative care team for advice about the anticipatory medication. The palliative care team advised staff to give Mrs I morphine every half an hour as needed and to consider starting a syringe driver.

67. The doctor documents they had discussed this advice with his supervisor who said it was ‘too early for a syringe driver currently’.

68. An hour later, records indicate the doctor attended the ward to speak to Mr I regarding the syringe pump. They noted Mrs I was more settled at this time.

69. At 5am a nursing note states Mrs I was a bit restless, and staff administered her prescribed medication. Just over an hour later nursing staff observed her to be comfortable.

70. At 11am that day records say nursing staff made Mrs I comfortable. There is no evidence she was unsettle or in pain at that time.

71. At 12.50pm we can see Mrs I’s daughter approached nursing staff stating that her mother was in pain and that the doctor had advised she could receive morphine every hour.

72. The nurse documented she did not consider Mrs I require pain relief because she had observed her to be settled. However, records indicate they contacted the palliative care team for specialist support.

73. Three hours later the specialist palliative care clinical nurse specialist (CNS) attended the ward. Records indicate Mrs I’s pain relief medication was discussed at length. The CNS explained to Mrs I’s daughter that, ‘sometimes despite our best efforts at making someone comfortable, there are times we cannot control 100% of symptoms’.

74. We asked our adviser if they considered nursing staff followed the end-of-life plan appropriately with regards to administering medication.

75. Our adviser said in their view staff acted in line with NICE NG31 guidance when managing the end-of-life care for Mrs I.

76. They added under this guidance, anticipatory medication should not be given automatically simply because it is prescribed or because a family member requests it. The medication is prescribed in advance so it is readily available quickly if symptoms develop. They said it is important the nursing staff reassess the patient’s actual symptoms and clinical need before administration.

77. They felt the clinical records evidenced the nurses regularly assessing Mrs I’s pain and medication was given, if in their professional opinion it was required.

78. We understand Mr I’s opinion of his wife’s distress and pain differs from that assessed by the nursing staff at the end of her life.

79. We can see staff followed NICE NG31 guidance. We cannot form an opinion on whether they appropriately assessed Mrs I and listened to the concerns of the family. We know Mr I is also upset about the way in which staff communicated with him at this time.

80. We can see in the Trust response that it said it had taken learning from the complaint and as result intended to: • implement ongoing education around appropriate analgesia (pain medication) and monitoring of pain and agitation in all patients • ensure communication is delivered clearly and sensitively at all times.

81. We went back to the Trust to ask it how it intends to implement change around this. It told us assurance can be given that the nursing staff are sent on the end-of-life study days to enhance their skills are knowledge around end-of-life care, including the administration of pain relief and syringe drivers.

82. It said when new staff join the ward, including health care support workers, it is a priority to send them on essential training as part of their induction.

83. The Trust added an end-of-life communication course is run for all nursing staff and covers a patient’s journey from admission to death and is based on complaints made about the Trust. It supports nursing staff to gain skills in being able to communicate in a sensitive and effective way. It added the ward plans to add more staff onto this course which runs 10 times a year.

84. We consider staff acted in line with NICE NG31 guidance. We can also see the Trust has taken on board Mr I’s complaint to ensure it improves any identified shortfalls in this area.

85. We hope the Trust’s response provides Mr I with some reassurance. We will not be taking this part of Mr I’s complaint further.

86. We thank Mr I for bringing his complaint to us. We are sorry he had to witness his wife dying and he felt she was in unnecessary pain. We do not underestimate how distressing this situation was for him. We offer our sincere condolences.

1. We have carefully considered Mr I’s complaint about Salisbury NHS Foundation Trust (the Trust). We are sorry to hear about the death of Mr I’s wife. We are particularly sorry he found the care the Trust provided to her at the end of life to be inadequate. We realise how distressing this time was for the family.

2. We have considered Mr I’s complaint that his wife was left as nil-by-mouth for an extended period. We understand how worrying this situation must have been. Our assessment indicates this did not have a significant impact on Mrs I’s overall condition.

3. Our view is that staff provided adequate care for Mrs I’s swollen legs. We appreciate Mr I’s frustrations around this issue.

4. We think staff did not treat Mrs I with the respect and dignity she deserved when they left her in an exposed state of undress. We can see the Trust has apologised and taken learning from this.

5. We have seen the Trust followed guidance regarding end-of-life care pain management. Additionally, we understand the Trust has taken on board Mr I’s complaint about this to make improvements.

6. We acknowledge the distress and concern Mr I has experienced with the loss of his wife. We understand this report cannot change what has happened. We hope it provides some clarity and reassurance as he continues to navigate his grief.