Home > Publications > Selected CasesHealth > Selected Investigations Completed AprilJuly 2002 > Part II, Case no. E.2132/99-00
Complaint against: Chorley and South Ribble NHS Trust (the Trust)
Complaint as put by Mrs F and Mrs G
1. The account of the complaint provided by Mrs F and Mrs G was that their father, Mr P, was re-admitted to Chorley and South Ribble District General Hospital, which is managed by the Trust, for urgent treatment on 15 October 1998. Mr P had serious health problems, and had been an inpatient at the hospital on a number of previous occasions during 1998. On one of those occasions, in May, he had been diagnosed as terminally ill. Mr P died in the hospital on 28 October 1998.
2. Mrs F and Mrs G complained to the Trust about the care and treatment their father received between July 1998 and his death. They considered his death was not as pain-free, peaceful and dignified as it should have been, despite previous assurances by senior clinical staff responsible for his care. Also, their father’s expressed wishes regarding his treatment, and those of his family, were opposed, particularly whilst he was a patient on the Rookwood unit at the Hospital, from 26 October. The family were also concerned that, whilst the need for an integrated care plan for their father’s treatment was agreed by the Trust in August, this was not implemented by the Trust before his death in October. This caused a lack of continuity of care with conflicting and confusing advice and care, resulting in distress for their father and the family. Despite meetings to discuss these and other issues and resultant apologies from the Trust, with assurances of changed practices and a review of services on the Rookwood unit, Mrs F and Mrs G remained dissatisfied and, in November 1999, requested an Independent Review of their complaint. On 1 December the Convener refused their request.
3. The matter subject to investigation was that the management of Mr P’s care was inadequate in that:
(a) there was no agreed treatment plan;
(b) there was a lack of communication between the medical and surgical team, and with the family, about what constituted palliative care and, consequently, inappropriate treatment was given;
(c) arrangements for consultant cover during the period 16-28 October 1998 were unsatisfactory; and
(d) Mr P was not given adequate pain relief, particularly in the last few days of his life.
Investigation
4. The statement of complaint for the investigation was issued on 21 August 2000. The Trust’s comments were obtained and relevant documents, including medical and nursing records, were examined. Four of the Ombudsman’s Professional Adviserstwo hospital consultants and two senior nursesadvised on the clinical issues. One of the Ombudsman’s Professional Advisers interviewed a senior member of the Trust staff. I have not put into this report every detail investigated but I am satisfied that no matter of significance has been overlooked.
Chronology of significant events
5. I detail below the chronology of significant events from 30 June 1998 until Mr P’s death on 28 October.
30 JuneMr P admitted to the Coronary Care Unit.
3 JulyMoved to Rookwood B ward.
10 JulyDischarged home.
11 JulyReadmitted to Coronary Care Unit and later that day transferred to Rookwood B ward.
17 JulyDischarged home.
18 JulyReadmitted to Coronary Care Unit with stroke and later that day transferred to Rookwood B ward. This admission was under the care of a consultant physician (the first Consultant Physician).
27 JulyTransferred to the care of another consultant physician (the second Consultant Physician) because of impending move to nursing home.
28 JulyThe second Consultant Physician prescribed morphine.
4 AugustThe second Consultant Physician was on holiday. Mr P seen by his registrar (the Registrar) who prescribed a Frusemide pump (a drug for the removal of fluid which is administered by mechanical or electrical pump).
5 AugustThe family had a meeting with the Trust Complaints Manager (the first Complaints Manager) following which Mr P was moved to Rookwood A ward.
7 AugustMr P seen by the Registrar who advised the family that he would be attempting to get Mr P to walk. This caused confusion to the family.
13 AugustMulti-disciplinary team meeting with the family regarding Mr P’s future care.
17 AugustMr P seen by the second Consultant Physician.
18 AugustMeeting with the family and the second Consultant Physician who reiterated the need for Mr P to have a peaceful time with 24 hour nursing care. He suggested the family look for a nursing home.
27 AugustMr P discharged to nursing home with morphine as required.
15 OctoberGP suggested that Mr P should be admitted as he was passing blood from his rectum. He was admitted to Rawcliffe ward, under the care of a consultant surgeon (the Consultant Surgeon). At the request of the family, Mr P was moved to a side room on Winstanley ward.
16 OctoberFollowing a discussion between the doctors, Mr P was referred back to the care of the second Consultant Physician who confirmed that only drugs should be given which would eliminate pain and distress. MXL (a morphine mixture) was prescribed. The second Consultant Physician went on holiday leaving Mr P in the care of the Registrar.
17 October – Mr P not given his MXL by the night staff.
18 OctoberMr P appeared to be having seizures.
19 OctoberThe Registrar prescribed medication for the seizures and Oramorph (an oral solution of morphine).
20 OctoberThe Registrar suggested that Mr P be put in a chair and that he should be fed more. The family disagreed.
21 OctoberFentanyl patch (a morphine-like drug) was prescribed which seemed more effective in relieving pain.
23 OctoberMr P deteriorated. Disagreement between family and medical staff over appropriate level of intervention.
25 OctoberMr P unable to swallow. Medication changed.
26 OctoberMr P transferred to Rookwood A ward. Medication being administered by syringe.
27 OctoberFentanyl patch administered late and reduced to half dose by the Registrar. He increased the dose of Oramorph and arranged to insert naso-gastric tube to administer fluids.
28 OctoberRelatives asked the on call doctor [the pre-registration House Officer] to increase the morphine by pump. The pre-registration House Officer told the family that that decision had to be taken by the Registrar. Mr P died.
Complaints (a) and (b) there was no agreed treatment plan; and there was a lack of communication between the medical and surgical team, and with the family, about what constituted palliative care and, consequently, inappropriate treatment was given
Definition of palliative care
6. The Ombudsman’s Nursing Adviser has advised me that palliative care does not mean a lack of action. She defined it as follows:
‘Palliative care, also called comfort care, is primarily directed at providing relief to a terminally ill person through symptom management and pain management. The goal is not to cure, but to provide comfort and maintain the highest possible quality of life for as long as life remains. Well rounded palliative care programmes also address spiritual and mental health needs. The focus is not on death, but on compassionate specialised care for the living. Palliative care is well suited to an interdisciplinary team model that provides support for the whole person and their family.’
Extract from clinical and nursing records
7. A member of the palliative care team recorded the following in the clinical records:
‘7/8/98 Palliative Care …
‘Following a long discussion Mr P makes a number of things quite clear:
He is aware of the terminal nature of his illness
He is prepared for his death but has intermittent fears that he [cannot] make any sense of
He is concerned about suffering and his family suffering when they watch him in distress
‘… he considers that the greatest fear he has is the breathlessness and the anxiety it creates. I have explained (at his request) the purpose of palliative care and my remit. I have explained that I deal with patients who whilst not in the physical manifestations of death have started down that road and the fear, anticipation [and] trepidation this can instil due to uncertainty [and] unpredictability of a dying trajectory.
‘…
‘14/8/98 Palliative Care Review. Much better physically [and] emotionally today. Limited conversation on previous topic as he feels more positive. He is aware of the service and is willing to talk further as [and] when needed.’
The following is recorded in the record of multidisciplinary communications:
‘15/10/98 [Relatives] have previously agreed with [Mr P] that he does not want any further active interventions, wishes to die peacefully … not for [resuscitation].
‘18/10/98 After a long discussion with Mr P’s daughter it has been expressed that the family wish to be consulted at all times. Where possible they wish to participate in all care and be involved with decisions made between medical and nursing staff.’
The following is recorded in the clinical records:
‘16/10/98 [The General Consultant Surgeon] … explained to the family that in view of Mr P not having a “terminal” illness per se it would not be advisable … to stop all his medications… [The General Consultant Surgeon] has [discussed with] [the second Consultant Physician] for assessment of [Mr P and] assuming care. …’
Back to top
Documentary evidence
8. On 28 February 1999 Mrs F and Mrs G wrote to the Trust detailing their dissatisfaction with Mr P’s care and treatment. Their letter included:
‘…
‘Because of his serious health problems and also the fact that he was very hard of hearing, he had made it known to the medical staff that his family should always be made fully aware of anything concerned with his medical condition. Because of his wife’s failing hearing and ill health, and consequent lack of understanding of situations, it was accepted by the consultants that discussions and decision making should include one of his children.
‘On 27 February 1998 he suffered a severe heart attack … Against all the odds he recovered sufficiently to return home. On 28 May 1998 he was again admitted to the [Coronary Care Unit] with heart failure, and we were told that he was not expected to recover, and that we should be prepared for his death …
‘[Following further hospital admissions and] after taking advice from the doctor, who felt it would not have been beneficial to use resuscitation, a decision was made [on 17 June] that … no resuscitation was to be used.
‘[After our father’s admission on 18 July] we began to feel that the ongoing situation and the family’s involvement was becoming a nuisance to some of the medical staff now in charge. …
‘On Tuesday 28 July 1998, [the second Consultant Physician] saw [our father] and prescribed Morphine. … to allow him to be more peaceful and comfortable, as he felt he was in pain and distress. Our father agreed with this, and we as a family were very relieved. … [The second Consultant Physician] advised us that the best way to deal with [our father’s] grave condition was to keep him as quiet, comfortable and pain free as possible, until his death. …
‘On Tuesday 4 August 1998, [the Registrar] saw him, as [the second Consultant Physician] was on holiday, and immediately ordered a Frusemide pump for 48 hours and monitoring of his liquid intake. He advised his fluid retention was dangerously high … We were increasingly concerned about the fact that several times we were informed that Rookwood B was a rehabilitation ward, and we felt that the majority of the staff were not aware that our father was not there for rehabilitation, but to have a peaceful, pain free death, so on 5 August 1998, in desperation, [we] made an appointment to see [the first Complaints Manager]. We discussed the medical needs and care and the seeming lack of staff awareness of the situation. This lady agreed and felt that it was now time for everyone to “start singing from the same hymn sheet”. Later that day she … advised that after lengthy discussions at the hospital, it was their suggestion that our father be moved to Rookwood A, as they felt that was a more appropriate ward for him. The following day he was moved to a side room on Rookwood A ward.
‘On Friday 7 August 1998, [the Registrar] saw him, changed some medication, and advised us that he would be attempting to mobilise our father by way of getting him to walk. This worried and totally confused us, as this was completely opposite to all the information we had been given.
‘On Tuesday 11 August 1998, [the Registrar] advised us of a possible discharge to Lake View Nursing Home. We did not feel happy about a major decision being made without consultation with [the second Consultant Physician], so we spoke to the Discharge Officer, also our father’s Social Worker … and the Nursing Sister on the ward. They called a meeting for the family to discuss ours, and their concerns, with [the Registrar].
‘On Thursday 13 August 1998, the family had an unbelievable meeting with [the Registrar, the Discharge Officer] and the Nursing Sister. This meeting was documented by the hospital staff present, and everyone was absolutely horrified at [the Registrar’s] attitude. This meeting ended with [the Registrar’s] comment of “if you do not want to take your father home, then put him in an institution” … the family [was] completely devastated.
‘[The second Consultant Physician returned] the following Monday, and … arranged a meeting with the family on Tuesday 18 August 1998 [where he] diplomatically defused the situation … and he reiterated how critically ill our father was, and how he needed a stress free, peaceful time, with 24 hour nursing care. On Thursday 27 August 1998, our father was discharged to the Springfield Nursing Home still under the care of [the second Consultant Physician] …
‘Sadly on Thursday 15 October 1998, after a very bad night, [our father’s] GP felt he needed admitting to hospital as he was [passing blood from his rectum] … he was admitted to Rawcliffe surgical ward, where surgery was mentioned, and we told the staff that our father did not want any unnecessary procedures prolonging his suffering. … We asked for some privacy for him, and advised we would not be leaving him alone, and he was moved to a side room on Winstanley ward.
‘On Friday 16 October 1998, … [the Consultant Surgeon] arranged a surgical procedure [proctoscopy – direct visual examination of the anus and rectum] on our father, and called in [the second Consultant Physician who] took [our father] into his care, reviewed the medication and the serious problems of administration of his medication by the medical staff, [and] confirmed that only drugs had to be given which would eliminate the pain and distress our father was feeling. He advised that the morphine would now be given in a long acting 24 hour release form. He advised us how critically ill [our father] was, and said we should not leave him. Another blow was dealt to us when he confirmed that he was about to go on leave for two weeks and that our father would be cared for by [the Registrar].
‘On Monday 19 October 1998, [the Registrar] prescribed extra medication for [our father’s] seizures, and extra morphine when needed. Our father was totally weak and unable to converse fully. So on Tuesday 20 October 1998, when [the Registrar] … advised my mother that he was intending having my father put into a chair the following day, and attempting to feed him more, you can imagine our utter shock and disbelief. Every family member [had been] told that whenever they were with our father they were to make sure that no one tried to move him out of his bed. As a family we were terrified of what was taking place.
‘On Friday 23 October 1998, we … saw a noticeable deterioration and [our father] appeared more distressed and in pain. A blood clot was noticed … in his catheter tube, the staff were told, he was put back on Frusemide. His breathing became very intermittent and a doctor was called [who] said she felt it was now best to leave him and wait for the inevitable. We agreed this was … best. 30 minutes later [the Registrar] arrived and insisted on putting a tube in his stomach for fluids. Mrs F told him, in the presence of other staff, that we were very unhappy as all these procedures were against our father’s expressed wishes … A heated argument followed, but again [the Registrar] walked out of the room and the tube was administered.
‘During the afternoon [of 27 October], the day before our father died, [the Registrar] reduced his morphine strength by half, to 25mg. He also inserted a tube into his nose down into his stomach to administer fluids. We are aware that [the Registrar] discussed these events with our mother, but as she was now so exhausted and distressed by the weeks leading up to this time, weeks of lack of sleep, not knowing if each day was going to be her husband’s last, and of helping her children keep a 24 hour vigil around their father’s death bed, she really was in no way able to comprehend what was being said or the reasons given for these actions.’
9. In a statement to the Trust dated 9 March 1999, in response to the complaint, a staff nurse from Rookwood A ward (the Staff Nurse) stated:
‘Mr P’s condition did fluctuate, on his good days he could walk to the toilet, … and on his bad days he was bed bound and fully dependent on nursing care. Mr P was a brave and pleasant gentleman who always tried hard to cope with his illness and expressed his desire that his family not suffer in watching him.’
10. In a statement to the Trust dated 9 March 1999, in response to the complaint, the Registrar stated:
‘Mr P was reviewed almost daily throughout his stay in hospital and at no time did I feel that there was any misunderstanding between myself and Mr P. I met with Mr P’s family on a number of occasions, which was extremely time consuming, each meeting lasting between 15 and 45 minutes.
‘…
‘I made every effort to explain Mr P’s medical condition in a manner which could be understood and tried to explain that on occasions [the family] were getting into areas that they did not fully comprehend. … It was however, stressed that we fully understood the need to keep Mr P happy and comfortable. …
‘… there were occasions when Mr P did not want his morphine to be given, that he stated he felt all right and did not want to become addicted.’ (See paragraph 32)
‘…
‘[At the meeting on 13 August] I did state to the family that they needed to sort out a care plan for Mr P that involved institutional care, meaning Residential or Nursing Home care, at which point I left the family.
‘…
‘Mr P was taking little nourishment via oral feed. Consequently intravenous fluids were administered, but unfortunately the drip tissued [leakage of fluids into tissues surrounding the injection site] on a number of occasions and [on 22 October 1998] it was decided to continue administration via a subcutaneous [under the skin] route … In view of Mr P’s [fluid retention] due to heart failure … subcutaneous fluids were uncomfortable … and he was unable to tolerate. … so I suggested a pureed diet. … As nutrition and hydration were obviously a problem, a decision was made to pass a naso gastric tube to ensure:
1) [pain relief]
2)
hydration
3)
anti-epileptic treatment
Mr P’s wife agreed with this approach.’
11. On 16 April 1999, after interviewing nursing and medical staff involved in Mr P’s care, the Chief Executive of the Trust (the Chief Executive) replied to the family’s letter of 28 February. His letter included:
‘It does appear that the care of your father did not follow a fixed plan of care which was agreed after discussion with yourselves and with your father and which was documented. The events that follow this appear to be the cause for the obvious loss of confidence and subsequent problems.…
‘Certainly [Mr P’s] poorly condition would never improve and the decision that should your father collapse he would not be resuscitated needed to be made. However, that is not to say that all medication should have stopped and only [pain relief] be given to your father. We have discussed this with the consultants involved and our Medical Director and to carry out this course of action would, we feel, have been detrimental to your father. Certainly had this occurred your father would have died in a far from dignified and peaceful manner.…
‘It was unfortunate that your father needed to be admitted to Rawcliffe ward [on 15 October 1998] and whilst we can understand and sympathise with the anxiety that discussion for probable investigations must have caused you, we do feel that [the Consultant Surgeon] made the correct assessment and decision in asking [the second Consultant Physician] … to take over his care.
‘… we believe that despite lengthy communication between [the Registrar] and yourselves there was still confusion as to what was to be given to your father as palliative care. …
‘We can only respond that [the Registrar’s] intentions in respect of your father were correct and that had your father not had these interventions to enable food and medication to be taken then a more uncomfortable death may have followed for him. We do, however, feel that at this time another member of the medical team should have been brought into the care of your father as certainly all confidence in [the Registrar’s] intentions had obviously ended. …’
12. On 8 September 1999 Mrs F and Mrs G attended a meeting with Trust staff. In a written record of the meeting, Mrs G stated that she had contacted the first Complaints Manager regarding a plan of care for her father and wanted to know why this plan of care was not followed. The second Consultant Physician explained that Mr P’s care had been discussed verbally with the medical and nursing staff and also with the family but it had not been formally documented. The first Complaints Manager informed the meeting that a new plan of care was currently being considered and documentation was shown.
13. The Consultant Surgeon explained that when Mr P had been readmitted to the surgical ward on 15 October 1998, it had to be decided if his condition was a surgical or medical problem. After a lot of investigations it was concluded that his condition was due to clotting of the blood. As this was a medical rather than a surgical problem he was therefore transferred to the care of the second Consultant Physician.
14. On 17 September 1999, following the meeting, the first Complaints Manager wrote a letter to Mrs F and Mrs G which included the following:
‘We have already commenced changes in the following areas:-
a review of nursing documentation to ensure streamlined communication is implemented.
the initiation of a medical plan of care taking into account patient and relatives’ wishes.’
Trust response to Ombudsman’s statement of complaint
15. On 13 September 2000 the Chief Executive stated:
‘Following investigations at the time of the original complaint, the Trust agreed that many of the problems arose because the agreed plan of care was not specifically documented. The medical, nursing and management staff within the Trust tried to communicate with the daughters of Mr P to explain the issues of palliative care that had been agreed. …
‘Discussions took place with Mr P and his family and a decision was made, that in the light of his terminal condition any further treatments were unlikely to prolong his life or improve the quality of his life. The Trust acknowledges that a well-documented plan of care would have facilitated better continuity of Mr P’s care. The Trust tried on numerous occasions to communicate with both the patient and all the family members and indeed this was quite extensive, even though the family remained dissatisfied with the content. The Trust feel that the communication between the medical and surgical teams was not an issue, as this was resolved by the change of consultant to [the second Consultant Physician] who was Mr P’s usual physician. This change occurred within twenty-four hours. The Trust disputes that inappropriate care was given, other than on the evening of his death when the Trust agreed that the junior doctor [the pre-registration House Officer] who reviewed Mr P should have contacted her senior to assist in the decision making regarding his pain relief.’ [Note: see complaint (d) paragraph 32]
16. On 2 November 2000, in response to further enquiries by the Ombudsman’s investigating officer, a new complaints manager (the second Complaints Manager), wrote stating:
‘… a documentation working party has been established. Currently, procedures pertaining to the withdrawal of treatment and decisions not to resuscitate patients is nearing completion. …
‘A documentation working group has produced a draft set of nursing documents which will be implemented as soon as approval is received. …
‘The issue of an acceptable proforma for medical use is being considered but as yet no firm decision has been made.’
The second Complaints Manager enclosed the set of draft documents referred to.
Back to top
Interview evidence
17. On 17 December 2001, the Trust’s Clinical Risk Manager (the Clinical Risk Manager) told one of the Ombudsman’s nursing advisers that the documentation working party was still in existence and its work was on-going. She explained that there is now common nursing documentation in use across the Trust and this has been extremely positive as a way of ensuring consistency; for example, when a patient moves from one ward to another, the documentation remains the same. There are prompts within the documentation that alert staff to ensure that they have followed issues through e.g. communication and contacts with family. There is ongoing evaluation of the documentation.
18. The Clinical Risk Manager explained that the Trust has now developed a “Do Not Resuscitate” (DNR) document. The documentation is recorded in triplicate; one copy goes to the clinical audit department to ensure that regular review of all DNR documentation is recorded; a second copy goes into the front of the medical case notes which is reviewed weekly on ward rounds; and a third copy goes into the nursing notes. This is to ensure that communication is improved and that all staff are aware of the resuscitation status. The Clinical Risk Manager added that the palliative care team is now training senior house officers [junior doctors in training] within the Trust.
19. The Clinical Risk Manager said that there had been other concerns about the Registrar’s attitude and he had now undergone a full re-training of his communication skills. She emphasised that there had never been any concern about the Registrar’s medical practice and there had been no criticism of his performance in this area.
Advisers’ comments
20. The Ombudsman’s Professional Advisers have provided the following advice:
‘The fact that there was no documented plan was totally inappropriate and poor practice. However, it is reassuring to note that the Trust has learnt from this complaint and reviewed its level of practice. Mr P was known to be terminally ill due to previous severe health problems. He was in severe heart failure which proved difficult to treat, had suffered a stroke and later developed bleeding from his bowel. His family wanted him to be kept comfortable while nature ran its course enabling him to die peacefully. Mr P’s condition did not deteriorate rapidly so that over a period of three and a half months decisions needed to be made about his management. The family’s involvement was appropriate but the doctors had to consider and re-evaluate the issues concerning withholding and withdrawing treatment at each stage. It is sad that the actions of the doctors did not meet the hopes of the family but there is no evidence that staff took actions other than those which they, in their clinical judgment, thought were in Mr P’s best interest and which were reasonable. For example, mobilisation was attempted because of the very high risk of Mr P developing bedsores which would have made his last illness even more unpleasant for him and his relatives, but on some days he was nursed in bed throughout the 24 hours. This management was sensitive to Mr P’s needs. The reasons given by the Registrar in his statement of 9 March 1999 for inserting the naso-gastric tube are reasonable. There is evidence of communication between the medical and the surgical teams. The surgical team carried out a proctoscopy which involves the use of a small instrument to provide a direct visual examination of the anus and rectum. This was entirely reasonable, particularly as the reason for Mr P’s admission on 15 October 1998 was because he was passing blood from his rectum. There is no evidence that an inappropriate procedure was carried out or that inappropriate care was given.’
Back to top
Findings
21. In reaching these findings I have taken into account the advice received from the Ombudsman’s Professional Advisers. Mrs F and Mrs G were concerned that their father’s care and treatment did not reflect what they understood had been agreed with Trust staff. They raised those concerns with Trust staff on a number of occasions including on 5 August 1998 with the first Complaints Manager. The first Complaints Manager agreed to speak to the second Consultant Physician and the Registrar. Despite this, no agreed treatment plan was documented or implemented. I can understand Mrs F and Mrs G’s concerns and frustrations at this.
22. I agree with the advisers that this was inappropriate and poor practice. The Trust has stated that Mr P’s care did not follow a fixed plan of care and the agreed plan of care was not specifically documented. The Trust has acknowledged that many of the subsequent problems arose because of this. I agree with that view. I uphold complaint (a).
23. I note, with approval, the measures that the Trust has subsequently taken on this issue. The Ombudsman’s Professional Advisers have advised me that they are reassured by the new documentation they have seen and by the procedures that have been developed by the Trust. These indicate that the Trust is trying hard to develop its practice and to learn from complaints, which is one of the key objectives of the NHS Complaints Procedure. I recommend that the new documentation and procedures introduced by the Trust are regularly monitored and reviewed to ensure ongoing compliance and revision as appropriate.
24. The clinical records show that there was communication between the surgical and medical teams. I am advised that it was entirely reasonable for the surgical team to carry out the proctoscopy and there was no evidence in the clinical records to suggest that the surgical team were considering carrying out an inappropriate procedure. The Trust has stated that the change in consultant occurred within 24 hours and, as a result of this, no inappropriate care was given. I accept that view. I also accept the advice of the Ombudsman’s Professional Advisers that it was reasonable, in the circumstances, to mobilise Mr P and to insert the naso-gastric tube.
25. I turn now to communication with the family. First of all, having seen evidence of Mr P’s sessions with a member of the Palliative Care team, I am satisfied that Mr P himself was clear about the meaning of palliative care. The Trust Chief Executive has stated that the fact that Mr P was not for resuscitation did not mean that all medication should be stopped and only pain relief given and that, despite lengthy communication between the Registrar and the family, there was still confusion about what constituted palliative care. I can understand the confusion the family must have felt and it is clear that the Registrar had problems with communication. I uphold complaint (b) only to the extent that there was a lack of communication with the family about what constituted palliative care. I note with approval that the Registrar has undergone full retraining in communication skills and the documentation and new procedures which have been developed by the Trust. I accept the advice of the Ombudsman’s Professional Advisers that no inappropriate care was given.
Complaint (c) arrangements for consultant cover during the period 16-28 October 1998 were unsatisfactory
Back to top
Documentary evidence
26. In the Trust’s written record of the meeting between Mrs F, Mrs G and Trust staff which took place on 8 September 1999, Mrs F stated that once the second Consultant Physician had gone on holiday problems started to occur. She also asked the question:
‘Why had [the Consultant Physician] not written down the conversation that had taken place between him and the family and [the] particular specifics before he had gone on holiday?’
Mrs F and Mrs G felt that it was very important that written documentation should be left if a consultant went on holiday.
27. In the Trust’s written record of the meeting the first Complaints Manager stated:
‘… communication did seem to break down with the family and [the Registrar] …
‘There should have been another doctor brought in.’
The record shows that the second Consultant Physician agreed with this view.
Trust response to Ombudsman’s statement of complaint
28. On 13 September 2000 the Chief Executive stated:
‘It is common practice that when [the second Consultant Physician] is on holiday that his work load is covered by his staff grade doctor in this case [the Registrar]. However, it is a standard arrangement that [the second Consultant Physician] arranges that his colleague [another consultant] is able to provide support to and cover for [the Registrar] in [the second Consultant Physician’s] absence.’
Advisers’ comments
29. The Ombudsman’s Professional Advisers have provided the following advice:
‘Every patient, while occupying an NHS bed in hospital, must be under the care of a named consultant. If the consultant is absent, for whatever reason, there should be a named consultant deputising. Mrs F and Mrs G were very concerned that the discussion which they had with the second Consultant Physician was not written down and left in place for other staff to act on in his absence on leave. It is normal practice for the workload to be covered by the Registrar and discussions to be made at that level. Only when the Registrar considered that he needed assistance would he call on help from another consultant. The nurses give continuous care and are used to working with the clinical staff in this way. These arrangements were reasonable but they were not made known to the family. There is nothing inherently unreasonable in this practice but lessons have been learnt and multidisciplinary care plans have now been developed including documentation of contacts with relatives and a continuing care plan.’
Back to top
Findings
30. In reaching these findings I have taken into account the advice received from the Ombudsman’s Professional Advisers. I am advised that the arrangements for consultant cover explained by the Chief Executive in his formal response to the Ombudsman’s statement of complaint are satisfactory. I accept that advice. However, I note that the Advisers say that a named consultant should have taken on the Second Consultant Physician’s responsibility for Mr P and the family should have been advised of that.
31. This was obviously a very difficult time for the family. I accept, as do the Trust, that during this period, the relationship between the family and the Registrar broke down. I agree with the view of the first Complaints Manager that another doctor should have been brought in. However, I have seen no evidence that the family asked to see a consultant and that request being refused. I do not uphold the complaint that consultant cover during the period in question was inadequate but I recommend that the Trust takes steps to ensure in future that such arrangements are made known to patients and their relatives.
Complaint (d) Mr P was not given adequate pain relief, particularly in the last few days of his life
Extract from nursing and clinical notes
32. The following entries have been made in the record of multidisciplinary communications:
‘11/8/98 Appeared to sleep well, did not want morphine, [Mr P] asked me this morning what tablet he missed, as he does not want to get dependant on morphine. …
‘26/10/98 Family concerned re: analgesia due to [Mr P’s] conscious state …’
The following entries have been made in the continuous evaluation sheet:
‘25/10/98 [Mr P] appeared to be uncomfortable earlier this pm. Oral morphine given with effect. Please monitor. [Mr P] has appeared comfortable overnight.’
The pre-registration House Officer who was called to see Mr P on 28 October recorded in the clinical notes:
‘…
‘Daughters extremely concerned over the fact that the patch of Fentanyl has been reduced. They believe that this is the cause of his deterioration. I am loath to ↑ Fentanyl patch as ? reason for reduction. [therefore] prescribed oramorph 10 mg / 10 mls down [naso-gastric] tube for breakthrough pain and chest.…’
Back to top
Documentary evidence
33. In their letter of 28 February 1999 to the Trust, Mrs F and Mrs G stated:
‘On Saturday 17 October 1998, [our father] appeared to have as comfortable day as possible. However, his obvious distress grew in the night and twice during that night … Mrs G … asked the nursing staff in charge if he had had his prescribed morphine, and if so did he need more pain relief. Twice she was told he had had it. She could not believe it when the following morning the night staff returned his notes to his room bearing a stick on note confirming to the day staff that his morphine had not been given. Mrs G immediately called the day staff nurse, who together with the sister, gave him some morphine.…
‘At 7am on the morning of Tuesday 27 October 1998, Mrs F took over from Mrs G to stay through the morning with him, and it was noted that although he had had not too bad a night generally, he was becoming more and more unsettled as the morning drew near. As the morphine patch, which was a three day patch, was due to be changed on this morning around 8am both daughters felt that he would become more settled once this was done.
‘A staff nurse came around 8am with the medication, but she did not attend to the morphine patch. This did not unduly worry us as we knew that it needed two members of staff to administer morphine, and we presumed this would be done once the ward’s medication round had been completed. At around 10.30am Mrs F asked a nurse if she could check when the patch was to be changed as our father was now in discomfort. His room was directly opposite the nursing station and Mrs F saw the nurse speak to the [Ward Sister]. [The Ward Sister] … told the nurse that the patch was a three day one and did not need changing. The nurse brought this message, and Mrs F informed her that she was aware of this, but as the patch had been put on at 8am on the previous Saturday, 24 October, it was now due for changing and she asked the nurse to inform the sister of this.
‘By around 11.15am no action had been taken and Mrs F spoke to the Staff Nurse who had earlier administered the drugs. She said that nothing could be done at that time as the Sister had gone for her break and it needed two to deal with morphine. She said that our father would have to wait until the Sister returned.
‘On her return to the ward the Sister came to the room and asked what was wrong. Mrs F told her that our father was very unsettled and that he should have the pain relief patch changed. The Sister then adopted a very authoritarian attitude and told her that she was not happy with him having a morphine patch.’
Mrs F and Mrs G explained in their letter that the patch was administered at 12.30 p.m. and they went on to say:
‘During that afternoon, the day before our father died, [the Registrar] reduced [our father’s] morphine strength by half, to 25 mg.
‘During the evening [of 28 October] Mrs G, together with our mother spoke to the Staff Nurse on duty and expressed their fears regarding the [naso-gastric] tube. Our mother wanted it removing, and we asked why had his morphine been reduced by half, when it was obvious he was in such pain and distress. We believed the time had well passed for him to be on … higher pain relief, not less, and we felt it should be administered by pump. We were told all this could be discussed with [the Registrar] in the morning, and when Mrs G asked would our father still be alive in the morning, no answer could be given. When pressed to explain why the morphine had been reduced by [the Registrar], the staff stated that [the Registrar] wanted our father to BE MORE ALERT.
‘We asked why should he be more alert to his pain and suffering and were told we would need to discuss this with [the Registrar]. Mrs G asked for a doctor to be called immediately, to re-assess the situation with a view to giving more pain relief …
‘Some time later [the pre-registration House Officer] arrived, examined him, his breathing sounded like a steam train, it was so loud. The doctor explained that although it was probably time for a higher dose of morphine to be administered by pump, the decision had to be [the Registrar’s]. Mrs G begged the staff to help our father, and some liquid morphine was attempted to be given but with little success. The staff explained that within a couple of hours we might see a slight improvement in his state, so his daughter had to just sit, watch and listen. It was the most awful experience and we truly believe that it was totally unnecessary.’
34. In his written response, dated 16 April 1999, to the family’s letter of 28 February 1999, the Chief Executive said:
‘The nursing staff on the night shift of the 17 October were unsure as to the manner the drug was prescribed and made the decision, that as they felt that your father was resting quietly, they would wait until the morning to review his prescription with the medical staff. However, given your own account that your father was distressed we have asked that the ward sister review this matter with the nurses involved. …
‘It had been mentioned on [26 October] that your father was very drowsy indeed and the nurses have documented that you were concerned about this. … As a consequence the [morphine] patch was not changed early on. … Later on because of the drowsiness the [morphine] patch dose was reduced. However, your father was still prescribed oramorph for any breakthrough pain which was increased from 5 mgs to 10 mgs. … [The Registrar] felt that this was the best management and would achieve an acceptable consciousness level and also relief of any discomfort.’
35. A written record of the meeting which took place on 8 September between the family and Trust staff showed that these matters were discussed at length and that Mrs F and Mrs G did not accept the Trust’s version of events that the family was concerned about their father being drowsy.
36. The Trust subsequently took statements from two nurses involved in Mr P’s care and wrote to Mrs F and Mrs G on 7 October stating:
‘The nurses both feel that because of your father’s condition at that time, that their comments made [in the nursing record] regarding the “consciousness level” was relating to him being drowsy, rather than too alert. … they were concerned that the drug was having too great an effect on your father’s breathing … had he been a little less drowsy, he may have been able to have tolerated some of the thickened fluids, which he could not tolerate in his current state. … I am aware that this opinion would obviously be in a direct contradiction to your own wishes for your father at that time and that you felt that he was too alert rather than drowsy.’
Trust response to Ombudsman’s statement of complaint
37. On 13 September 2000 the Chief Executive stated:
‘There is a dispute between the family and the staff regarding this issue. The Trust acknowledges that it was difficult to balance the level of pain relief needed by Mr P particularly as Mr P did not have any intractable reason for his pain. The staff’s intention was always to balance the level so that Mr P was kept comfortable whilst not causing further deterioration of his condition. However, … the Trust do feel that the issue of his medication on the evening of his death should have been referred to a more senior member of the medical staff for consideration.’
Back to top
Interview evidence
38. On 17 December 2001, the Clinical Risk Manager told one of the Ombudsman’s Professional Advisers that clinical risk training is now undertaken for the two intakes of new doctors per year. It is ensured that there is good training of doctors to understand their accountability and to ensure that they obtain advice and support from their more senior colleagues on all occasions. Training in pain relief is covered by support from the palliative care team which consists of medical and nursing healthcare professionals who work Trust wide but are based in the Cancer Specialist Unit. They support education of pain management and are available for advice when needed.
Advisers’ comments
39. The Ombudsman’s Professional Advisers have provided the following advice:
‘The family knew that Mr P was going to die and they wanted him to die peacefully. The medical and nursing staff found it difficult to provide appropriate treatment and support in Mr P’s terminal illness. Their aim was to keep him as comfortable, alert and free of pain as possible. Staff continued to assess Mr P and clearly he was deteriorating. Mrs F and Mrs G would have preferred drugs to be increased to ensure that Mr P was pain free. There is no evidence in the notes that his level of pain was high or increasing. Given the staff concerns about Mr P’s breathing, it was not unreasonable to reduce the Fentanyl patch given that there was a prescription for Oramorph for breakthrough pain. The reduction in the Fentanyl patch was not the cause of Mr P’s deterioration. The actions of the clinical staff were not individually unreasonable but lacked the co-ordination which the further training now aims to provide. The distress caused to Mrs F and Mrs G cannot be underestimated. Given the concerns of the family and the pre-registration House Officer’s relative inexperience, it would have been appropriate for her to speak to a more senior doctor on call. Although I do not condone the action at the time, the Trust is to be commended on the approach it is now taking to teaching the management of terminal pain. This is an area which has been developing over the last few years and it is hoped that lessons learnt from this complaint will serve as a foundation for better treatment of other patients in the future.’
Back to top
Findings
40. In reaching these findings I have taken into account the advice received from the Ombudsman’s Professional Advisers. It is very difficult to balance the level of pain relief with consciousness levels and I note that there were occasions recorded in the nursing notes when Mr P, who did not want to become addicted, refused his morphine. The clinical records show that staff were monitoring the level of Mr P’s consciousness and attempting to balance the level of pain relief with his breathing difficulties. On 17 October 1998 the night staff did not give Mr P his morphine. The Trust has stated that this matter has been raised with the staff concerned (see paragraph 34).
41. During the last few days of his life, Mrs F and Mrs G were concerned that Mr P was too alert while staff have stated that they felt he was too drowsy. I accept, as does the Trust, that there is disagreement between Mrs F and Mrs G and staff on Mr P’s level of consciousness. I have not made any finding on Mr P’s level of consciousness and consider that it is not possible to do so. I am advised that the actions of staff in reducing the Fentanyl patch were not unreasonable given their concerns about his breathing. I accept that advice. Given Mrs F and Mrs G’s view that their father was too alert, I can understand the distress and upset the reduction in the Fentanyl patch must have caused. The Trust has stated that the issue of Mr P’s medication on the evening of his death should have been referred to a more senior member of the medical staff for consideration. The Ombudsman’s adviser agrees with this view. I uphold the complaint only to the extent that Mr P should have been given his pain relief medication on 17 October and the pre-registration House Officer should have referred to a more senior member of staff for advice on 28 October.
Conclusions
42. I have set out my findings in paragraphs 21 to 25, 30 to 31 and 40 to 41. The Trust has asked me to conveyas I do through my reportits apologies to Mrs F and Mrs G for the shortcomings I have identified and has agreed to implement the recommendations in paragraphs 23 and 31.
Short report of this investigation
Previous < Contents > Next
Back to top
|
