Palliative care data gaps
Lack of a specified palliative and end-of-life care data set, hindering integrated care boards from understanding population needs.
Source spread
Where this theme appears
This theme appears across 13 independent accountability sources, so the source mix matters as much as the headline total.
4 inquiry recs
3 PFD reports
83 committee recs
2 HSSIB recs
10 CQC actions
5 PPO recs
11 IMB recs
1 IMB report
2 detention investigation recs
50 PHSO decisions
6 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(4)
36 — Research into child sexual abuse
Recommendation: Research should be urgently undertaken into all forms of child sexual abuse and in particular cases of multiple abuse and into the provision of personal social services in the islands authorities and the less populated areas of Scotland (15.84-88).
Unknown
R71 — National CDI death monitoring
Recommendation: Scottish Government should identify a national agency to undertake routine national monitoring of deaths related to CDI.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
38 — Improve perinatal mortality recording
Recommendation: Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units …
Gov response: 103. We accept this recommendation. We will explore the feasibility of publishing data about the safety and quality of maternity services at individual Trust level. 104. As recommended by the Morecambe Bay Report, MBRRACE-UK has …
Accepted
IR2-5 — Classification of Infections and Severity
Recommendation: I recommend that infections eligible for compensation should be classified in the following manner: a) there should be defined categories for each type of eligible infection, and the stages through which it progresses, and for each category defined degrees of …
Gov response: The Government recognises the different levels of suffering from different infections and degrees of severity. Therefore, compensation will be available for all of the categories of loss recommended by the Inquiry - these are referred …
Accepted
Prevention of Future Deaths reports(3)
Peter Seale
Concerns: The coroner identified a lack of national guidance for monitoring patients with pleural plaques, leading to inconsistent medical approaches and a risk of patients being lost to follow-up, potentially delaying early diagnosis and treatment.
Overdue
Tyler Ryan
Concerns: The coroner identified a chronic shortage of Paediatric Pathologists causing delays in reports, which postpones genetic testing for surviving siblings. There are also concerns regarding the underuse of molecular autopsy and the need to revise the SUDIC Protocol.
Response (NHS England): • NHS England implemented recruitment incentives and e-learning resources to attract pathologists into higher specialist training. • NHS England is working with professional bodies to develop a curriculum for placental … (AI summary)
Response (GMC): • The GMC obtained legislative changes to make evidence requirements less prescriptive for specialist recognition. • The GMC invested in additional facilities and personnel, increasing the number of places available … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care stated that officials would continue to discuss workforce capacity and genetic screening with NHS England counterparts. • The NHS Long Term Workforce … (AI summary)
Overdue
Boycie Chatterton
Concerns: The coroner notes that a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases is absent, which experts stated would improve outcomes and survival rates.
Overdue
Select committee recommendations(83)— showing 50 strongest matches
#14 —
Recommendation: The ageing prison population has and will continue to increase the need for end-of- life and palliative care in prisons. We welcome the publication of the Dying Well in Custody Charter and the good practice at some establishments. But standards …
Response attribution not verified
#12 —
Recommendation: The Department and NHS England told us that data on patient-level activity from hospices, which ICBs need in their role as commissioners, is not strong or robust enough, because hospices are only obliged to report activity data when they are …
Response attribution not verified
#12 —
Recommendation: We urge the department to mandate ICBs to maintain a fully populated palliative and end of life care dashboard that is actively used for commissioning, service planning, quality improvement, and inequality monitoring across their local system. (Recommendation, Paragraph 52)
Response attribution not verified
#11 —
Recommendation: National palliative and end of life care data provide valuable insight into patterns of healthcare use and location of death, however the evidence presented demonstrates substantial gaps in local data collection and utilisation. Without consistent, granular and timely data, ICBs …
Response attribution not verified
#27 — Departmental annual report shows significant omissions on preventative and end-of-life care.
Recommendation: The NHS Long Term Plan states that ill health prevention helps the public to stay healthy, as well as moderating demands on the NHS. The Department recognised in its 2023–24 Annual Report that there “is still much work to do …
Response attribution not verified
#15 —
Recommendation: Prisoners applying for early release on compassionate grounds should have their applications processed in an efficient and timely manner. This is especially important for terminally ill prisoners near the end of their lives. We recommend prisons identify a single member …
Response attribution not verified
#25 —
Recommendation: The NAO report describes how independent hospices offer additional services that are typically outside the remit of the NHS, for example certain complementary therapies, funded from hospices’ charitable donations. Hospices offer support to the family, friends and carers of those …
Response attribution not verified
#22 —
Recommendation: Some hospices have recently reduced the volume or range of services they provide and others are planning to do so, at a time when demand for palliative and end-of-life care is rising.45 Hospice UK told us that hospices are facing …
Response attribution not verified
#19 —
Recommendation: Professor Murtagh told us that for a long time it has been known that around one in four adults who need palliative care do not get it, and that recent research suggests that the proportion may now be even higher.36 …
Response attribution not verified
#17 —
Recommendation: Professor Murtagh stressed that ICBs need to commission on the basis of activity and outcomes. Professor Murtagh explained that this approach is already used elsewhere in the NHS through a blended payment model that aligns payments with incentives, and questioned …
Response attribution not verified
#9 —
Recommendation: NHS England told us that although it does collect patient-level activity data, it needs to start collecting more. It currently does not collect activity data from all hospices and therefore cannot determine how much care ICBs are buying from hospices, …
Response attribution not verified
#1 —
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health and Social Care (the Department) and NHS England on the provision of palliative and end-of-life care, and the funding of …
Response attribution not verified
#5 —
Recommendation: The Department and NHS England are not responding to the growing financial crisis in the adult hospice sector with the seriousness and urgency needed. The independent hospice sector is facing a serious financial situation that is already affecting patient care. …
Response attribution not verified
#4 —
Recommendation: Too many patients spend their last days receiving palliative care in acute hospitals, which does not always achieve the best outcomes for patients nor represent value for money. Patients are frequently receiving palliative care and reaching the end of their …
Response attribution not verified
#2 —
Recommendation: Only now are the Department and NHS England developing a Modern Service Framework for palliative and end-of-life care, but so far the details are unclear. There has not been a new national strategy for improving palliative and end-of-life care in …
Response attribution not verified
#22 —
Recommendation: We recommend that the Government moves towards sustainable and predictable models of funding for hospices, financing their running as well as investment costs, which reflects the increasingly central role they will play in delivering end of life care. This funding …
Response attribution not verified
#20 —
Recommendation: The Government must hold ICBs to account for delivering bereavement services. This does not need to wait for the forthcoming Modern Service Framework as there are already clearly defined expectations for what ICBs should deliver in this area. In its …
Response attribution not verified
#19 —
Recommendation: Bereavement, and pre-bereavement support are essential, yet access remains patchy, poorly commissioned, and often difficult to navigate. Despite its inclusion in the current Ambition Framework, significant gaps persist, particularly for culturally diverse communities and children and young people. (Conclusion, Paragraph …
Response attribution not verified
#18 —
Recommendation: The Government need to publish an evidence-based plan, supported by up-to-date workforce modelling, setting out how it will increase the capacity and sustainability of all sectors of the specialist palliative and end of life care workforce, as part of the …
Response attribution not verified
#17 —
Recommendation: Current shortages in the specialist workforce are putting palliative care services in an unsustainable position which threatens their ability to deliver equitable and high-quality palliative and end of life care. Extensive consultant vacancies, impending retirements, limited training places and widespread …
Response attribution not verified
#16 —
Recommendation: We recommend that end of life care be included as a core skill for the generalist health and social care workforce, with a clear and defined set of competencies required to deliver high-quality and person-centred palliative and end of life …
Response attribution not verified
#10 —
Recommendation: We recommend that the Department implement the 90% target for the percentage of individuals in the last year of life documented on the Palliative Care Register and that it reports annually on progress against this target to monitor the impact …
Response attribution not verified
#9 —
Recommendation: We support increasing use of the Palliative Care Register for early identification of individuals, including children and young people with PEoLC needs. However, we are concerned that its use is likely to decrease given the removal of funding incentives for …
Response attribution not verified
#7 —
Recommendation: We recommend that the MSF includes specific guidelines and requirements for ICBs to enable access to 24/7 PEoLC services, including access to symptomatic medication, and in-person care where necessary. We call on the Government to provide an assessment of both …
Response attribution not verified
#6 —
Recommendation: It is unacceptable that access to 24/7 palliative and end of life care services remains patchy throughout England. Individuals nearing the end of life should be able to access the right care, advice and medication, wherever they are and regardless …
Response attribution not verified
#5 —
Recommendation: We are concerned that the Minister was unable to commit to providing clear and specific standards and guidance for babies, children and young people’s palliative and end of life care in the Modern Service Framework (MSF). We strongly recommend that …
Response attribution not verified
#53 — Record detailed post-16 pathway and long-term outcome data for care-experienced individuals.
Recommendation: The Department must record data on post-16 pathways and attainment for those with care experience—including detailed data on qualifications, course types and completion rates. The Department should also monitor long-term outcomes—employment quality, income levels, and 100 higher education progression for …
Response attribution not verified
#6 — Skills England faces challenges with data collection, levy system, and programme communication.
Recommendation: Skills England has been broadly welcomed by the further education and skills sectors. We agree with the Government’s priorities for Skills England, including identifying national and local skills needs, simplifying access to training, and collaborating with employers and training providers …
Response attribution not verified
#11 — Gather annual transport manufacturer data on vocational training effectiveness; report findings to DfE, DWP.
Recommendation: The Department for Transport should on at least an annual basis gather information from British transport manufacturers on how effectively the UK’s vocational training system is delivering a robust pipeline of skills, and report these findings to the Departments for …
Response attribution not verified
#7 — Collect and publish intersectional data on victims of religiously and racially aggravated hate crimes.
Recommendation: The Government should collect and publish data on the religion, ethnicity and sex of victims of both religiously and racially aggravated hate crimes to help policymakers understand the extent of anti-Muslim hate crimes and the role gender plays in such …
Response attribution not verified
#26 —
Recommendation: Baroness Finlay emphasised the role that hospices have as an important source of expertise in palliative and end-of-life care, available to professionals in the NHS such as district nurses and care assistants.58 NHS England told us how hospices support training …
Response attribution not verified
#24 —
Recommendation: NHS England agreed that the hospice sector is fundamentally in financial distress and that there is a need to move quickly to resolve and fix the problems. But it stressed the need to avoid perpetuating problems, such as supporting a …
Response attribution not verified
#23 —
Recommendation: NHS England emphasised that it is aware that every hospice provider is worried about financial sustainability, but that it is unaware of any hospices facing immediate closure.50 It told us it expects ICBs to undertake quality impact assessments if a …
Response attribution not verified
#21 —
Recommendation: Professor Murtagh stressed the importance of having earlier conversations with patients and their families about possible deterioration and approaching death, to ascertain their wishes. Without such conversations, patients may continue to have high-cost treatment they may not benefit from.43 NHS …
Response attribution not verified
#20 —
Recommendation: The Department and NHS England agreed that there are gaps in provision of palliative and end of life care and that it must meet demand where it is needed.39 They also acknowledged the importance of moving care away from costly …
Response attribution not verified
#16 —
Recommendation: NHS England told us that ICBs are required to understand the needs of their populations and their projections of future demand.30 NHS England acknowledged that it must take the lead on establishing a single commissioning approach for the provision of …
Response attribution not verified
#15 —
Recommendation: ICBs currently fund hospices largely through grants and block contracts, which do not provide clarity over what is being purchased.28 The Department and NHS England acknowledged that there must be a move away from funding hospices in this way towards …
Response attribution not verified
#13 —
Recommendation: The Department and NHS England told us about the ‘Modern Service Framework’ they are currently developing, which they intend will bring together disparate elements of the system and will set out what “good” commissioning for palliative and end-of-life care looks …
Response attribution not verified
#10 —
Recommendation: There has not been a renewal of the government’s approach to delivering and improving palliative and end-of-life care in England since the first national strategy was published in 2008. The Health and Care Act 2022 introduced a legal duty for …
Response attribution not verified
#6 —
Recommendation: The NHS is at risk of losing the huge value it gains from independent hospices beyond the provision of statutory palliative and end-of-life care. Independent hospices provide enhanced care compared with the NHS, such as complementary therapies, funded from charitable …
Response attribution not verified
#3 —
Recommendation: NHS England has been too slow to enforce a commissioning approach for the provision of palliative care that focuses on the quality of outcomes for patients. ICBs continue to fund hospices largely through grants and block contracts, despite the NHS …
Response attribution not verified
#21 —
Recommendation: Hospices form an integral part of palliative and end of life care provision at home and in the community and we welcome the fact that the Government intends for them to play a bigger role as part of its shift …
Response attribution not verified
#13 —
Recommendation: Poor data sharing and lack of integration across NHS, social care, voluntary and private providers creates confusion, delays and gaps in continuity for people at the end of life, frequently placing the burden of coordination care on patients and carers …
Response attribution not verified
#8 —
Recommendation: The role of social care in the provision of palliative and end of life care has been overlooked for far too long, and we are concerned that the Government’s plans to remove local authorities from ICBs will only make the …
Response attribution not verified
#4 —
Recommendation: If the Modern Service Framework is to deliver meaningful change it must be more than a well-intentioned ambition. ICBs and the Department need to be held accountable for meeting the Framework, with clear consequences if its standards are not met. …
Response attribution not verified
#3 —
Recommendation: We are unclear about what is fundamentally different about this framework compared to existing documents, such as the Ambitions Framework and the NHS National Standards for Palliative and End of Life Care. In particular, what different approach it will take …
Response attribution not verified
#2 —
Recommendation: We welcome the Government’s plans to introduce a Modern Service Framework to set national standards for palliative and end of life care services, and the Department’s commitment to co-produce this work alongside key stakeholders. However, we approach this with a …
Response attribution not verified
#51 — Care leavers face significant challenges transitioning into further education, employment or training.
Recommendation: Care leavers face significant challenges transitioning into further education, employment or training. Care leavers aged 19–21 are three times more likely not to be in education, employment or training than their peers. There is insufficient support for those transitioning into …
Response attribution not verified
#14 — Develop an evidence-led plan to increase diversity within the transport manufacturing sector.
Recommendation: Skills England should by the end of 2026 set out an evidence-led plan, commissioning research necessary to fill gaps in knowledge on what has worked best in the manufacturing sector, detailing how it will support the Government’s target to increase …
Response attribution not verified
#23 — Home Office monitors police efficiency program progress, while College seeks measurement consistency.
Recommendation: We asked whether the Home Office had the data needed to monitor progress towards its planned savings of £354 million by 2028–29.58 The Home Office said it is important to get the right data to hold police 51 Qq 75-77, …
Response attribution not verified
HSSIB safety recommendations(2)
Variations in the delivery of palliative care services to adults
Identify and describe the palliative and end of life care services in their areas through engagement with integrated care partnerships and third-sector organisations. This is to provide the public and health and care professionals with accessible and accurate information about …
Safety Action
Variations in the delivery of palliative care services to adults
HSIB recommends that NHS England specifies a palliative and end of life care data set to help integrated care boards to understand their populations’ demographics and needs, in order to support commissioning and improvement of services.
Safety Recommendation
NCEPOD recommendations(3)
CQC inspection actions(10)
Mount Vernon Cancer Centre
The trust should consider ways to introduce an end of life care dashboard.
Should Do
Diana Princess of Wales Hospital
The service must have an effective system which accurately identifies and tracks end of life and palliative care patients.
Must Do
Poole Hospital
Continue to develop the end of life performance dashboard to capture information to ensure access and flow.
Should Do
St Benedict's Hospice
The service should record and monitor referral to treatment times and national care of the dying audit data to ensure services are in line with provider targets.
Should Do
Clifton Hospital
The trust should consider including mental health, learning disability and autism needs in their model for identifying patients for supportive and palliative care.
Should Do
Mount Vernon Cancer Centre
The trust should ensure that training on the electronic palliative care coordination system (EPaCCS) is delivered to eligible staff.
Should Do
Ash Court Care Centre - Camden
We recommend that the provider seeks further training on how to gather information on people's end of life wished and preferences.
Should Do
Smyth House
Improvements were required to end of life care planning to ensure it reflected people's preferences in sufficient detail, in line with best practice guidance such as the Gold Standards Framework.
Should Do
Figtree Care Services Ltd
How people would like to be cared for, if they wished to be admitted to a hospital or hospice or the support they would like from staff was not included. This is an area to improve further.
Should Do
Barons Down Nursing Home
The provider must ensure people have access to a range of activities which are meaningful to them and that people's end of life care wishes are known and recorded.
Must Do
PPO death in custody recommendations(5)
The Head of Healthcare
The Head of Healthcare should ensure that all patients who have life limiting conditions have an advanced care plan in accordance with NICE guidelines.
The Head of Healthcare
The Head of Healthcare should ensure that an end-of-life register is in place at HMP The Verne that enables early identification of those patients with palliative care needs and to proactively plan for end-of-life care.
The Head of Healthcare
The Head of Healthcare should ensure that staff are appropriately trained and clinically competent to deliver end-of-life care as per NICE [NG31] and the ‘Dying Well in Custody Charter’.
The Head of Healthcare at HMP Northumberland
The Head of Healthcare at HMP Northumberland should review the care management of patients with a cancer diagnosis. This should include ensuring each patient has an identified lead nurse who will oversee the implementation of a plan of care, including …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that there is a process in place to transfer prisoners with a terminal diagnosis or whose medical needs cannot be met at The Verne to a more suitable environment at the earliest …
IMB individual recommendations(11)
The Verne (2024)
The Minister to consider establishing an end-of-life care facility at HMP The Verne.
Other
Noted
Altcourse (2020)
Altcourse is seeing, as are other prisons, an increase in its age profile. Many older prisoners require more age-appropriate accommodation, enhanced or more specialised healthcare provision, and in some cases end-of-life care and palliative care. The prison developed an excellent older person’s strategy, but this could only be partially implemented owing to finite finance and lack of an overarching national …
Ministry of Justice
In Progress
Rye Hill (2022)
The difficulties surrounding appropriate arrangements for end-of-life care and compassionate release, imposed by current HMPPS facilities and procedures, impact HMP Rye Hill disproportionately because of the higher than average age profile of the prisoners held. The current procedures do not seem to facilitate humane treatment of these prisoners.
HMPPS
In Progress
Usk and Prescoed (2025)
The ageing population at HMP Usk presents several challenges. The increased demand for both general and palliative healthcare will necessitate additional resources and funding, such as expanded weekend services and more staff allocated to hospital escorts. Furthermore, the current infrastructure at HMP Usk is not well suited to the needs of older individuals. What specific measures are being considered to …
HMPPS
In Progress
North Sea Camp (2020)
Address the need for an end of life care suite at HMP North Sea Camp.
HMPPS
In Progress
Bure (2020)
Will consideration be given to providing special accommodation and resources for palliative care at HMP Bure, and developing further cells to provide better conditions for the disabled?
HMPPS
Partially Accepted
Rye Hill (2023)
The Board is still concerned that not one compassionate release has been agreed despite a number of applications and despite the increase in the number of terminally ill prisoners dying in custody at Rye Hill.
HMPPS
Rye Hill (2024)
The Board was pleased that one terminally ill prisoner was given compassionate release during the reporting period. However, the Board is still concerned that the process remains unnecessarily difficult, particularly as it requires a GP’s diagnosis of terminal illness to be confirmed by a hospital consultant. The long waiting times to see an NHS consultant add unnecessary delays, which can …
HMPPS
Noted
Long Lartin (2024)
Healthcare centre (HCC): what full programme of measures is planned to provide all necessary facilities (including end of life) for in-patients?
HMPPS
In Progress
Lancaster Farms (2020)
There is a lack of wheelchairs to support prisoners with reduced mobility accessing health care and other amenities. Certain cases have illustrated difficulties of working with external agencies for the support and potential release of those with palliative care needs (see paragraphs 8.5 and 8.9).
Governor / Director
Cardiff (2023)
The last health needs analysis in HMP Cardiff took place in 2017. Will the Health Board now address this issue urgently?
NHS / Healthcare Provider
Accepted
Detention investigations(2)
Assessment of government progress in implementing the report on the … — Rec 38
The Home Offce should devise and publish a strategy for reducing the number of deaths from natural causes and those that are self-infcted in, and shortly after, immigration detention.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 34
The Home Offce should review whether fgures relating to deaths in and after detention should be issued on a regular basis.
Immigration Detention
PHSO casework decisions(50)
P-001867 — The Princess Alexandra Hospital NHS Trust
Mrs E complained about her son's palliative care, citing conflicting information, unexplained syringe driver use, unmanaged pain, and no doctor review available in his final hours.
NHS in England
Mar 2023
P-003498 — A practice in the Suffolk area
Mrs R complained the Practice did not appropriately manage her late husband's palliative care, specifically regarding pain relief and a delayed hospice referral, causing unnecessary suffering.
NHS in England
Apr 2025
P-003663 — East Kent Hospitals University NHS Foundation Trust
Mrs M complained about her husband's lack of treatment, an incorrect gastroscopy decision, and poor communication, believing these failings contributed to his premature death.
NHS in England
Upheld
Jul 2025
P-001182 — Imperial College Healthcare NHS Trust
Mr O complained the Trust made assumptions about his partner, Miss I, leading to cancelled surgery, premature end-of-life declaration, and denial of food/water. He also criticised the complaint handling.
NHS in England
Upheld
Nov 2021
P-001635 — A medical practice in the Havering area
The complainant alleged her husband was not added to the palliative care register, resulting in inadequate pain management and care, and potentially shortening his life.
NHS in England
Oct 2022
P-001894 — Manchester University NHS Foundation Trust
Ms R complained the Trust failed to manage her mother's pain effectively before her death and exhibited poor communication, causing confusion and distress to the family.
NHS in England
Mar 2023
P-002256 — University Hospitals Birmingham NHS Foundation Trust
A son complained his dying father was publicly informed of his condition, discharged without support, lacked appropriate home assessment and transport, and received no bereavement counselling.
NHS in England
Oct 2023
P-002593 — Croydon Health Services NHS Trust
Miss A complained the Trust failed to inform her mother's cancer was terminal and provided poor end-of-life care, specifically inadequate pain relief.
NHS in England
Partly Upheld
May 2024
P-002913 — An independent provider in the Hull area
Miss M complained a doctor failed to prescribe correct end-of-life medication for her mother and a nurse failed to facilitate additional medication, causing her mother pain and distress.
NHS in England
Partly Upheld
Sep 2024
P-003424 — A practice in the Walsall area
Miss R complained the Practice and Trust delayed diagnosing her sister's cancer, prescribed ineffective antibiotics, poorly communicated diagnosis, and provided poor palliative care.
NHS in England
Partly Upheld
Mar 2025
P-003478 — Midlands Partnership University NHS Foundation Trust
Ms A complained the Trust inappropriately placed her mother on end-of-life care, withdrew treatment and food, used a syringe driver unnecessarily, and communicated poorly, leading to her mother's death.
NHS in England
Apr 2025
P-003681 — University Hospitals Sussex NHS Foundation Trust
Miss Q complained that staff did not provide her father with sufficient palliative pain relief when he was at the end of his life, causing him distress and visible injury.
NHS in England
Partly Upheld
Jul 2025
P-004371 — Lewisham and Greenwich NHS Trust
Mrs E complained about delays in her father's care and discharge, an unfair COVID-19 test request, and false claims about medication delivery, causing distress.
NHS in England
Nov 2025
P-004404 — Warrington and Halton Hospitals NHS Foundation Trust
Dr D complained the Trust ignored her father's pain, delayed palliative care, and a nurse made racist comments, causing him extreme suffering.
NHS in England
Dec 2025
P-004533 — Central London Community Healthcare NHS Trust
Mrs H complained the Trust's palliative care phone was unresponsive and text messages ignored, preventing her from getting emergency end-of-life support for her husband.
NHS in England
Dec 2025
P-001312 — A care provider in the Leeds area
Mr N complained about poor palliative wound management for his nonverbal cousin, Mr O, resulting in a maggot infestation in his facial tumour and distress for the family.
NHS in England
Feb 2022
P-001411 — A medical practice in the Hampshire area
Mrs E and Mrs S complained their late mother was prematurely discharged from a Hospice. They also alleged the Practice failed in domiciliary care, syringe driver arrangements, urinary infection testing, and contacting the Hospice.
NHS in England
Upheld
Jun 2022
P-001504 — A medical practice in the Luton area
Mrs O complained the Practice failed to arrange end-of-life medication for her mother, did not visit her while her condition deteriorated, and wrongly cancelled a prescription.
NHS in England
Aug 2022
P-002653 — Gateshead Health NHS Foundation Trust
Mr E complained the Trust wrongly put his mother on end-of-life care with excessive sedation, accelerating her death in 2018.
NHS in England
May 2024
P-002719 — The Hillingdon Hospitals NHS Foundation Trust
Mrs C complained about poor pain management for her late husband, an inappropriate high dose of pain relief, and the family not being informed he was nearing end of life.
NHS in England
Upheld
Jun 2024
P-002824 — University Hospitals Birmingham NHS Foundation Trust
The Trust allegedly kept Mrs G's mother in hospital unnecessarily, mismanaged her nutrition/hydration, failed to communicate deterioration, and made incorrect discharge record entries.
NHS in England
Jul 2024
P-003367 — County Durham and Darlington NHS Foundation Trust
Mr O complained the Trust discharged his father-in-law without diagnosis, caused preventable pressure sores, made incorrect specialist referrals, and failed to diagnose a spinal stroke.
NHS in England
Upheld
Mar 2025
P-003491 — South Tyneside and Sunderland NHS Foundation Trust
Mrs A complained the Trust ignored her husband's wish to be re-intubated and excluded her from discussions, leading to delays, infection, and his subsequent death.
NHS in England
Apr 2025
P-003702 — Ashford and St Peter's Hospitals NHS Foundation Trust
Mrs B complained the Trust inappropriately discharged her husband multiple times, delayed diagnosis and treatment, and provided poor, delayed palliative care, causing suffering and a non-peaceful death.
NHS in England
Partly Upheld
Jul 2025
P-003643 — University Hospitals of Derby and Burton NHS Foundation …
Mr B and family complained about contradictions in imaging, false assertions of neurological stability, failure to re-refer to neurosurgeons, and an inappropriate patient transfer.
NHS in England
Partly Upheld
Jul 2025
P-003738 — United Lincolnshire Teaching Hospitals NHS Trust
Mrs M complained the Trust delayed her mother's liver tests and brain cancer diagnosis. She also complained Marie Curie staff failed to administer end-of-life medication correctly.
NHS in England
Aug 2025
P-004304 — Royal Devon University Healthcare NHS Foundation Trust
Mrs K complained about her husband's inadequate pain management, delayed communication of his cancer's spread, and slow involvement of the Speech and Language Therapy team.
NHS in England
Partly Upheld
Nov 2025
P-004390 — Leeds Teaching Hospitals NHS Trust
Ms E complained the Trust missed opportunities to diagnose her mother's cancer sooner, failed to provide adequate pain relief, and excluded family from DNR discussions.
NHS in England
Dec 2025
P-004439 — The Princess Alexandra Hospital NHS Trust
A man complained about his mother-in-law's care, citing poor hygiene, inadequate investigation of deterioration, mistaken morphine administration, and unsuitable discharge.
NHS in England
Dec 2025
P-004784 — A practice in the Oadby and Wigston area
Ms A complained the practice decided her mother should be nil by mouth without a proper assessment, and about the time taken and lack of communication in complaint handling.
NHS in England
Upheld
Feb 2026
P-001295 — Tameside and Glossop Integrated Care NHS Foundation Trust
Daughter complained her father developed a pressure sore due to inadequate care and lack of family communication. She also alleged poor bladder/bowel care and medication errors.
NHS in England
Upheld
Feb 2022
P-001293 — United Lincolnshire Hospitals NHS Trust
Ms A complained the Trust inappropriately discharged her client, Mr H, to an empty home instead of a hospice, leading to him being found distressed and dying two days later.
NHS in England
Feb 2022
P-001314 — The Rotherham NHS Foundation Trust
Mrs O complained the Trust moved her husband to palliative care and withheld intubation/ventilation without his consent, denying him a last chance of survival from COVID-19.
NHS in England
Feb 2022
P-001456 — East Suffolk and North Essex NHS Foundation Trust
Mrs H complained her father received incorrect medication, untreated pressure ulcers, insufficient physiotherapy, unconsulted care orders, and a delayed continuing healthcare checklist.
NHS in England
Partly Upheld
Jul 2022
P-001464 — Ashford and St Peter's Hospitals NHS Foundation Trust
Miss U complained about poor communication and misinformation from the Trust while her father received palliative care, causing her additional stress and sadness.
NHS in England
Jul 2022
P-002005 — East Kent Hospitals University NHS Foundation Trust
Mrs A complained about inadequate oncology and neurology care for Mr A, including incorrectly reported scans, a missed brain tumour diagnosis opportunity, and failure to provide pain relief.
NHS in England
May 2023
P-002283 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Mr D complained the Trust failed to diagnose his wife's cancer in 2019/2020 and failed to effectively manage her pain in her final months.
NHS in England
Upheld
Nov 2023
P-002287 — Solent NHS Trust
Mrs M complained Trust staff failed to provide her father with a good supply of syringe driver medication, leading to him dying in pain and causing her family distress.
NHS in England
Upheld
Nov 2023
P-002809 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Miss B complained about her mother's care during two admissions, including pressure ulcer deterioration, a missed MRI, and mischaracterisation of dementia, which she believed led to her mother's premature death.
NHS in England
Jul 2024
P-002868 — Northern Care Alliance NHS Foundation Trust
Mrs L complained the Trust provided inadequate end-of-life care for her mother and that prescribed steroid medication contributed to her death.
NHS in England
Aug 2024
P-003028 — A practice in the Leeds area
Mr & Mrs R complained the care home provided inadequate end-of-life care and the Practice failed to address their concerns for their mother in 2019, potentially shortening her life.
NHS in England
Oct 2024
P-003274 — United Lincolnshire Teaching Hospitals NHS Trust
Ms N complained about delayed oesophagus cancer treatment, lack of information about her brother's prognosis, poor communication, wrong infection information, and unaddressed care wishes.
NHS in England
Jan 2025
P-003383 — Cambridge University Hospitals NHS Foundation Trust
Mr R complained the Cambridge MDT concluded his wife was unfit for surgery based on misrepresentative information and communication failings between Trusts, causing a lost opportunity for earlier, life-extending surgery.
NHS in England
Not Upheld
Feb 2025
P-003625 — Stockport NHS Foundation Trust
Mr E complained about his mother's end-of-life care, including a doctor's refusal for more time, staff not giving palliative medication, a nurse refusing a doctor call, and delayed palliative care.
NHS in England
Jun 2025
P-003635 — Royal United Hospitals Bath NHS Foundation Trust
Miss X complained Royal United Hospitals Bath NHS Foundation Trust provided poor care to her father, Mr X, including delayed cancer follow-up, lack of specialist input, inappropriate discharge attempts, and poor communication about his prognosis.
NHS in England
Not Upheld
Jun 2025
P-004037 — Mid and South Essex NHS Foundation Trust
Mr R complained the Trust delayed investigating his mother's ovarian cancer, draining abdominal fluid, and commencing chemotherapy. He also alleged unsafe discharge, failure to ensure palliative care, and poor communication, causing her unnecessary suffering.
NHS in England
Upheld
Sep 2025
P-004016 — Northern Care Alliance NHS Foundation Trust
Mrs L complained the Trust failed to promptly administer a morphine syringe driver for her mother Ms R's end-of-life care and did not inform Ms R of long-term risks when prescribing steroid medication, contributing to her death.
NHS in England
Sep 2025
P-004437 — University Hospitals Bristol and Weston NHS Foundation Trust
Miss C complained the Trust failed to regularly monitor her aunt, delayed palliative care, delayed symptom review for six hours, and did not communicate her aunt's prognosis confidentially.
NHS in England
Nov 2025
P-003432 — North East Ambulance Service NHS Foundation Trust
Mr E complained the Trust delayed referring his wife to oncology and provided inadequate pain relief, causing additional suffering and uncertainty about her prognosis.
NHS in England
Partly Upheld
Mar 2025
P-004434 — An independent provider in the East Hampshire area
Complaint alleged a trust discharged a mother when she was unfit and without end-of-life medication, and a nursing home failed to provide medication, use a BIPAP machine, or correctly hoist her.
NHS in England
Partly Upheld
Nov 2025
LGO / SPSO decisions(6)
21-005-391c — Boots UK Limited (21 005 391c)
Summary: We consider Boots UK Limited contributed to delays getting end of life medication to Mrs C before she died. Mr B suffered avoidable distress witnessing his mother in pain before she died. Boots should pay Mr B financial redress to recognise his injustice.
LGO (Local Government & …
Health
Upheld
Mar 2022
21-005-391 — Wirral Metropolitan Borough Council
Summary: We consider Boots UK Limited contributed to delays getting end of life medication to Mrs C before she died. Mr B suffered avoidable distress witnessing his mother in pain before she died. Boots should pay Mr B financial redress to recognise his injustice.
LGO (Local Government & …
Adult Care Services
Not Upheld
Mar 2022
21-005-391a — The Orchard Surgery (21 005 391a)
Summary: We consider Boots UK Limited contributed to delays getting end of life medication to Mrs C before she died. Mr B suffered avoidable distress witnessing his mother in pain before she died. Boots should pay Mr B financial redress to recognise his injustice.
LGO (Local Government & …
Health
Not Upheld
Mar 2022
NIPSO-202001016 — Western Health and Social Care TrustNorthern Ireland Hospice
The daughter of an elderly cancer patient complained that her syringe driver was removed in the days before her death, causing her to experience unnecessary pain.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Dec 2024
21-016-410 — The North Northumberland Hospice
We upheld a complaint about end-of-life care. The Care Provider will apologise and review its procedures for record-keeping.
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
23-013-793a — High Peak Lodge (23 013 793a)
Summary: We uphold Mrs Y’s complaint about her grandmother’s care. We found fault with Mrs X’s continence care and some aspects of her end of life care. We also found fault with the Care Home’s record keeping and the Council’s communication. As a result, Mrs X did not always receive …
LGO (Local Government & …
Health
Upheld
Aug 2024