A practice in the Breckland area

3. Mrs A complains about the end-of-life care provided to her husband, Mr C, by the Practice in March 2025. Specifically:

• Mrs A had to travel to hospital to change her husband’s medication chart as it was wrong. She then had to travel to a pharmacy to collect more end-of-life medication for his syringe driver as it had run out.

4. Mrs A complains about a lack of organisation by Norfolk Community Health and Care NHS Trust (NCH) regarding her husband, Mr C’s, end-of-life care from 5 March to 2 April 2025. Specifically:

• five opportunities were missed to review her husband’s medication during March 2025 • inconsistent handovers leading to confusion around her husband’s Methadone and Dexamethasone prescriptions.

5. Mrs A complains about care provided to her husband, Mr C, by The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust (QEH) from July 2020 to September 2024.

6. Mrs A says that inadequate care from the Practice and NCH meant she was left in an inconvenient and stressful situation regarding her husband’s end of life medication. As Mrs A does not drive, she was left ‘running around’ trying to deal with the situation. Mrs A had to organise a lift and leave her autistic children to look after their father who was at the end of his life. Mrs A also says that QEH failed to carry out appropriate investigations promptly which would have diagnosed her husband’s cancer sooner. All this has taken a toll on the health of Mrs A and her children. Mrs A says she should never have been put in that position and feels let down.

7. As a set of outcomes, Mrs A wants apologies from the Practice, NCH, and QEH, as well as a financial remedy.

8. Mr C was in his 50s. He had a background of kidney cancer and had undergone surgery in December 2024 to reduce his tumour burden. Mr C also suffered with reflux oesophagitis, lumbar disc degeneration, asbestos exposure, recurring vomiting, abdominal pain, and ischaemic heart disease, with some symptoms first reported in 2020.

9. By March 2025, Mr C had been referred for palliative care as his cancer had spread. This included end of life medication such as Methadone and Dexamethasone which Mrs A was helping him to manage.

10. Unfortunately, throughout March 2025, there were missed opportunities to review Mr C’s medication and Mrs A had to travel to hospital to change his medication chart (as it was wrong) and then collect more medication as supplies had run out. Sadly, Mr C died on 2 April 2025.

Practice and NCH

12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Practice and NCH have already done enough to put right the impact of these events.

13. Mrs A is concerned that she had to travel to hospital to change Mr C’s medication chart as it was wrong. She then had to travel to a pharmacy to collect more end-of-life medication for his syringe driver as it had run out. Mrs A is also concerned that there were missed opportunities to review Mr C’s medication, as well as inconsistencies and confusion around his prescriptions. We appreciate this was stressful and inconvenient for Mrs A, as well as causing her some uncertainty about Mr C’s care.

14. Mrs A says she complained to the Practice on 10 July 2025. It replied on 10 November 2025. The Practice apologised for Mrs A having to travel to the hospital and the pharmacy to update Mr C’s medication chart and get additional supplies of medication for him.

15. The Practice also outlined three specific action points in response to Mrs A’s complaint. Firstly, to ensure staff pay special attention to the practicalities for families and next of kin before and during end-of-life care. This includes transportation of relevant medication. Secondly, a commitment to improve information sharing with out-of-hours services, community services, and the local hospital. Thirdly, to ensure no patients requiring anticipatory/end of life medications are left with a shortfall during out of hours.

16. Given these assurances of remedial action by the Practice, we consider that Mrs A’s concerns have been appropriately addressed, and there is no further action for us to take.

17. Mrs A says she complained to NCH on 4 September 2025. It replied on 24 October 2025. NCH apologised that Mrs A had had to raise concerns about Mr C’s care. It also apologised that it did not meet her expectations and for any distress caused. NCH acknowledged there were missed opportunities to review and update Mr C’s medication charts, inconsistent handovers leading to confusion about his prescriptions and an unreasonable burden placed on Mrs A when she was asked to attend hospital.

18. To address Mrs A’s concerns, NCH outlined several action points. Mrs A’s concerns were reviewed to identify learning and improvement opportunities. Meetings were held with relevant staff/teams to empathise the importance of proactive medication management. Also, regarding the decision to send Mrs A to hospital, the nurse involved has been contacted to ensure clearer understanding and improved practice in similar future circumstances.

19. Given these assurances of remedial action by NCH, we consider that Mrs A’s concerns have been appropriately addressed, and there is no further action for us to take.

QEH

20. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We have discussed this with Mrs A to understand the reasons why she could not do so. We have also considered the time QEH has taken to respond to Mrs A.

21. Mrs A complained to QEH on 28 July 2025. It replied on 2 October 2025. Mrs A brought her complaint about QEH to the Ombudsman on 11 November 2025. According to QEH’s reply, Mrs A’s complaint was about Mr C’s care from July 2020 until September 2024. Therefore, this episode of care started approximately five years before Mrs A submitted her complaint to QEH.

22. If this episode of care finished in September 2024, it is unclear why Mrs A could not have submitted a complaint to QEH then rather than waiting until July 2025. We appreciate that Mrs A was helping to manage Mr C’s end of life care from approximately March 2025 and that Mr C sadly died in April 2025. After this, we acknowledge that Mrs A completed local resolution and came to us promptly, approximately four months after she submitted her complaint to QEH.

23. Therefore, we asked Mrs A why she did not complain to QEH sooner than she did, but she did not provide any specific details about relevant timings or any explanation for the significant delay. Mrs A says she did not become aware of a problem with Mr C’s care until 2 April 2025 which is the date of his death. We understand why Mrs A gives this as her date of knowledge, but she also told us that Mr C was ‘in and out of hospital’ before this with various symptoms and he was not given appropriate investigations to try and diagnose his cancer more promptly.

24. Given this, if Mrs A’s concerns about Mr C’s care cover the period July 2020 until September 2024, we consider her date of knowledge could be earlier that she has said. As such, it seems likely Mrs A could have complained to QEH much sooner than she did. If Mrs A had done this and completed local resolution, she could have approached us sooner with her complaint.

25. We are sorry to hear about Mr C’s historical experiences with QEH and that ultimately, he was diagnosed with cancer and sadly died. This must have been a devastating experience for Mrs A and her family, and we do not underestimate the impact of these events.

26. In summary, we have looked at Mrs A’s complaint about QEH, but we consider it is now out of time for our purposes and there are insufficient grounds for us to waive the time limit on this occasion.

1. We have carefully considered Mrs A’s complaints about the Practice; Norfolk Community Health and Care NHS Trust and The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust.

-we have decided the Practice and Norfolk Community Health and Care NHS Trust have already done enough to put right the impact of these events on Mrs A and her family -the complaint about Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust falls outside of our time limit and we have decided there is no good reason for us to put our time limit aside to consider it further.

2. We are sorry to hear about the tragic circumstances around Mrs A’s complaints. We recognise the impact that Mr C’s sad death has had on Mrs A and her family.