Barts Health NHS Trust

3. Mrs S complains about aspects of the care and treatment provided to her husband, Mr S, by the Trust between March and April 2024. She specifically complains the Trust:

• did not appropriately manage Mr S’s pain between 13 and 26 March • provided a poor standard of care and hygiene support • did not adequately communicate with Mrs S about Mr S’s condition and care • there was a lack of continuity of nursing and medical staff.

4. Mrs S says these events meant Mr S suffered in the weeks before his death, his care was inconsistent, and it was difficult for her to find out information. She says the mismanagement of his pain medication led to Mr S experiencing opioid toxicity for several days.

5. Mrs S says Mr S was extremely confused, hallucinating and he could not explain where his pain was. She says because of the poor care by the Trust, the last few weeks of Mr S’s life were dreadful, and it was devastating to watch her husband in such pain and confusion. This has caused her significant and ongoing distress.

6. As an outcome to her complaint, Mrs S would like an acknowledgement and service improvements.

7. Mr S had terminal metastatic cancer and was prescribed oxycodone (an opioid medication) for pain relief. Prior to his admission he was receiving 15mg of oxycodone MR (slow release) per day, and 3ml of OxyNorm (a form of oxycodone for immediate pain relief) to be given when required up to four times per day as needed (PRN).

8. Mr S attended the Emergency Department (ED) at the Trust on 12 March 2024 with chest pain. The working diagnosis was chest sepsis.

9. On 13 March, the Trust moved Mr S to an Acute Assessment Unit (AAU). On 14 March, the Trust moved Mr S to a respiratory medicine ward under the care of the medical team. During this time, treatment for an infection continued and he was given pain relief for his bone cancer symptoms.

10. Mr S sadly died on 3 April.

14. 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 with each part of Mrs S’s complaint.

Pain management

15. Mrs S complains the Trust did not adequately manage Mr S’s pain between 13 and 26 March 2024. She says the dosages of oxycodone MR (10ml / 5ml) given between 13 and 18 March were too high, and the number of OxyNorm PRN given per day (three) were too low between 13 and 26 March. She says this caused opioid toxicity. This occurs when an individual ingests more opioids than their body can tolerate. We have considered the Trust’s pain management of Mr S with the help of our adviser.

16. NICE palliative cancer guidance on managing bone pain says:

• consider radiotherapy • follow palliative care pain guidelines • consider a stepwise approach, using the World Health Organization analgesic ladder • the breakthrough dose may need to be individually titrated.

17. Mr S had terminal metastatic cancer which had spread to his bones. He had previously undergone radiotherapy.

18. Our adviser explained it can be very difficult to get this kind of pain under control, and it is common for medical and palliative care teams to make changes to dosages when a patient comes into hospital to try and help make them more comfortable. They explained dosages may be increased then reduced to attain this, and there may also be side effects from the pain medication.

19. From Mr S’s medical records we can see a conversation took place between the Trust’s palliative care team and Mrs S on 14 March 2024 regarding Mr S’s pain medication dosages.

20. The Trust explained Mr S was in a lot of pain on admission and it usually titrated up pain medication. This is the process of gradually adjusting a drug’s dosage to find the lowest effective amount that provides maximum benefits with minimal side effects. It noted Mrs S explained Mr S is sensitive to opioids and slow titration is important. The Trust explained it would discuss this with the palliative care consultant and would titrate the oxycodone. It noted it should update Mrs S whenever there were changes.

21. The palliative care consultant recommended continuing with oxycodone MR 15mg every 12 hours and changing the dose of oxycodone solution to 3mg -5mg every four hours when required.

22. The Trust had another discussion with Mrs S on 18 March. We can see from the notes Mrs S asked for the 3mg-5mg PRN dosage to be reduced to 3mg only. The Trust agreed to this. Mrs S also asked if the team could check regularly and offer PRNs as Mr S’s confusion meant he did not proactively ask for it. The Trust made a note that nurses should be proactive in checking the need for PRN, which could be given four times a day if needed.

23. Mrs S says Mr S experienced opioid toxicity as a result of incorrect dosages. She says his symptoms included delirium, hallucinations, and he could not explain where his pain was.

24. Marie Curie guidance on delirium says many conditions cause delirium, including having an infection, being dehydrated and poorly controlled pain. It says anyone can develop delirium, but those at higher risk are people who are approaching the end of life and people who are on lots of medicines or have several health problems.

25. Our adviser explained it is important to note there can be many reasons for a patient to experience delirium. As Mr S had an infection, this is likely to have been an important contributor to the delirium described. This is in line with the Trust’s explanation.

26. We understand Mrs S has vast experience in caring for Mr S and providing his medications. We can see she kept pain charts and had recorded the doses given for his pain medication since September 2023. We do not underestimate how difficult it must have been for Mrs S to see Mr S deteriorate during his admission.

27. We appreciate Mrs S believes Mr S was suffering from opioid toxicity, based on their previous experience of this. As noted above, there are many reasons why someone can suffer from symptoms of delirium and we are unable to establish this was a direct result of opioid toxicity rather than the infection. We have reviewed the dosages given and when, with the help of our adviser. Based on the information we have seen, we consider the Trust acted in line with guidance in its management of Mr S’s pain.

Care and hygiene support

28. Mrs S says the Trust left Mr S unwashed, did not change his bed linen, and provided poor care throughout his three-week admission. She says he was in a poor condition when she arrived at the Trust on several occasions.

29. In its response, the Trust explained on several occasions Mr S would decline personal care and a change of bed linen when offered and would tell staff that he would wait for his wife to come and help. It says during Mrs S’s visits she would often help Mr S, and the Trust would offer to change the bed linen.

30. GMC guidance explains you must provide a good standard of care.

31. We reviewed Mr S’s medical records. Nursing handover notes show the Trust assisted Mr S with personal care and hygiene needs on some days and gave minimal assistance on others.

32. We do not underestimate how worrying it must have been for Mrs S to see Mr S unwashed and without fresh bed linen on certain visits to the Trust. While the Trust says care was declined on occasion, this is not supported in the records. We think the Trust could have done more to ensure better care to meet Mr S’s needs in line with the above guidance.

33. The Trust has apologised that high standards of care were not always met and explained it has reminded staff to document conversation with patients and update relatives of patient’s decisions. It says it has implemented further processes, with staff being reminded to stay within the bays.

34. The Ombudsman’s Principles for Remedy explain that providing fair and proportionate remedies is an integral part of good complaint handling, and where a public body has failed to get things right and this has led to an injustice, it should take steps to put things right.

35. Appropriate remedies can include apologies, remedial action, and financial remedies, and in addition to this, public bodies should ensure that all feedback and lessons learnt from complaints contribute to service improvement.

36. The Trust has acknowledged high standards of care were not always met and explained what actions it has taken to address this. We consider this is a fair and proportionate remedy in line with the Ombudsman’s Principles of Good Complaint Handling and for Remedy.

Communication and staff continuity

37. Mrs S says the Trust did not adequately communicate with her about Mr S’s condition and care. She says it was a battle to find out what was happening, and she was not present during certain conversations between the Trust and Mr S.

38. She says there was a lack of continuity of medical care during Mr S’s admission and there was a different consultant each week as well as many agency staff, most of whom were on the ward for one day.

39. In its response, the Trust apologised it relayed important information to Mr S about his treatment when he was alone and confused, and Mrs S was not present.

40. It explained permanent nursing staff primarily cared for Mr S, with there only being two instances where agency staff cared for him, and he was always assigned a named nurse. It explained there is a consultant of the week system in place which works very well for patients, with each outgoing consultant providing a thorough handover. It also explained the medical team were able to keep Mrs S updated regularly regarding Mr S’s care plan, and unfortunately it is not possible for medical teams to call relatives as often as they would like.

41. The consultant model study says a general medicine consultant of the week model shortens hospital length of stay and improves the patient journey.

42. We reviewed the records with the help of our adviser. We have seen multiple teams were involved in Mr S’s care. We also know the Trust has a consultant of the week system in place which it says works very well, in line with the above study. Our adviser explained this is common practice in hospitals throughout the UK.

43. Our adviser noted good documentation in the medical notes that highlight doctors involved with Mr S’s care had sound knowledge of the clinical picture. We can see the Trust updated Mrs S on multiple occasions throughout Mr S’s admission, including 31 March where our adviser noted it explained Mr S’s condition and treatment plan clearly.

44. We appreciate it must have been upsetting for Mrs S to learn the Trust had shared information about Mr S’s treatment with him while she was not there. Based on the evidence we have seen, overall, we are satisfied the Trust’s communication was appropriate and in line with guidance. We have seen no indications of failings in the Trust’s continuity of staff.

Summary

45. In summary we have seen no indication that anything went wrong with the Trust’s management of Mr S’s pain, its communication with Mrs S or its continuity of staff. Where we have seen indications of failings in its provision of care and hygiene support, we think the Trust has taken appropriate action to put this right.

46. We recognise the events leading up to Mr S’s death have been devastating for Mrs S and we are very sorry for her loss. We thank her for bringing her complaint to us.

1. We thank Mrs S for bringing her complaint to us. We know the events complained about have been very upsetting for Mrs S, and we offer our sincere condolences on the death of Mr S.

2. We have carefully considered Mrs S’s complaint about Barts Health NHS Trust (the Trust). We have seen no indication that anything went seriously wrong with its management of Mr S’s pain, its communication with Mrs S or the continuity of medical staff. Where we have seen indications something went wrong with the standard of care and hygiene support, we think the Trust has taken appropriate action to put this right.