Poor symptom control
These cases show how pain, agitation and other distressing symptoms were not adequately controlled as people neared the end of their lives. This caused additional unnecessary suffering for the person who was dying, and also for their loved ones, who were by their bedside in their final days and hours. In many cases, this distress could have been avoided.
Young man dying from cancer suffered for over 11 hours because hospital failed to give effective pain relief
Mr T was a 29-year-old man who had been diagnosed with widespread cancer. He had stopped responding to treatment and was admitted to hospital with persistent vomiting. It was clear that his health was deteriorating and his family, as well as those involved in his care, agreed that he was dying. As nothing more could be done to treat his cancer, Mr T was transferred to the palliative care unit (the unit) for ongoing support. One of the core goals was to make sure he was pain-free in the last days of his life.
Before being transferred to the unit, Mr T had been receiving continuous pain relief through a syringe driver. At around 1pm on the day that he was transferred, Mr T had been suffering increased pain, restlessness and agitation, so the sister on the unit requested a review of Mr T’s pain relief from the on-call doctor. By 8.30pm, the on-call doctor still had not come, so the sister contacted her again. The on-call doctor advised her to call the palliative care advice line about increasing the dose.
After talking to the advice line, the sister spoke to the on-call doctor again to ask that she write up the new prescription for Mr T. However, there had been a change of shift and the new on-call doctor said that she could not come to the unit for an hour. By 11pm, an on-call doctor had still not arrived. Unable to watch her son suffer any longer, Mr T’s mother – who had been at his bedside all day – contacted A&E and spoke to an on-call doctor. A surgical doctor then attended at 11.40pm, and prescribed increased pain relief for Mr T, which was set up at 12.30am the following day. Mr T died two days later.
Witnessing her son in the last days of his life was extremely upsetting for Mr T’s mother. But knowing he was in pain during this time, and feeling those responsible for caring for him were not relieving his discomfort, added to her sadness and distress. She recalled how her son had pleaded with her: ‘Mum please get me out of here. I’m better looked after on ward seven when the doctor comes straight away’.
What we found
One of the main goals of Mr T’s care was to keep him pain-free because he was so close to death. We found that Mr T experienced unnecessary pain and distress for more than 11 hours because the on-call doctors did not respond to the sister’s request to review his pain medication, and this issue was never escalated to senior staff.
In addition to this, we found that the delays in Mr T’s pain relief meant his mother endured a significant level of additional distress because she had to watch her son in unnecessary pain during the last hours of his life.
Mr T’s mother told us that she wanted changes to be made so that the ‘same thing that happened [to her son] does not happen to anyone else’.
Woman received two lots of sedative and no pain relief because of problems with equipment
Ms K was a 55-year-old woman who was terminally ill with cancer. At the point she was admitted to the hospital, Ms K was suffering from pain and was becoming increasingly distressed and agitated. Three weeks after her admission, a palliative care consultant prescribed a sedative and pain relief to be given by two subcutaneous syringe drivers (these administer a steady dose of medication under the skin).
Two days after the medication was started, a nurse recorded that one of the syringe drivers was faulty, and a replacement was found to have a low battery. The nurse did not record whether the low battery in the new syringe driver was a problem or whether any action had been taken to resolve this. The records show that due to the faulty syringe driver, Ms K had much less medication than prescribed. In addition to this, staff discovered that both syringe drivers contained the sedative, which meant Ms K was receiving no pain relief to make her feel more comfortable in the last stages of her life. Staff noted the error in Ms K’s records later the same day, and both syringe drivers were stopped. After a review by the palliative care team, the syringe drivers were restarted.
There was no indication that Ms K was assessed in light of the error or that the hospital looked into the effect having extra sedative and no pain relief would have had on her. Ms K died a week later.
Ms K’s brother told us that before the problems with the syringe driver, his sister was communicating, but following the incident she was so drowsy that she was unable to speak to him. Her brother said this meant they didn’t get the chance to say goodbye to each other. He was also concerned that his sister suffered unnecessary pain as a result of the error.
What we found
We found that the records for Ms K were so poor that we could not say how or when the syringe driver error occurred, or for how long Ms K received a double dose of sedative. A nurse should have verified the contents of the syringe driver before starting Ms K’s medication, and this should have been properly documented on the records. Neither of the syringe drivers delivered the prescribed medication at the correct rate, and no reason for this was given in the records.
Once hospital staff spotted the error, they did not take the appropriate actions to make sure that no harm had come to Ms K, and there was no information to suggest that the incident was properly investigated. The Trust’s poor record keeping and failure to thoroughly investigate the incident at the time meant we were not able to reassure Ms K’s brother that his sister did not suffer or experience unnecessary harm and pain at the end of her life as a result of the mistake.