1. To make sure mistakes stop happening.
2. To make public services better for everyone.

Goals:

• Goal 1 is to make an impact on public services.
• Goal 2 is to make sure people who use the service have a good experience.
• Goal 3 is to raise awareness of PHSO.

Background

Taking someone from hospital to die at home is a major undertaking for both the hospital and the patient’s family or caregivers.

The transition inevitably disrupts a patient’s care and comfort. The disruption could no doubt be managed and accommodated if there is sufficient time. But if time is short, and particularly if problems arise, there can be chaos and confusion at a time when the dying patient and their family need a calm, orderly environment.

My husband was in palliative care in hospital in early 2022 and was discharged to die at home following his wishes. From the moment the decision was made to take him home, we faced many problems.

To name a few: Hospital staff had great difficulty coordinating everything required for his move home and his discharge was chaotic and delayed by more than 48 hours as a result; we experienced bullying and coercion by a nurse, who wanted us to leave when there was no hospital bed at home for my husband or confirmation one would arrive; there were errors in the supply of medication we received and its documentation (we’d received chemotherapy medication that wasn’t prescribed, but no supply of other prescribed medication, and no supply of pain relief medication in a form my husband could take as his condition had deteriorated during the delay); and there were errors in the information recorded in my husband’s discharge summary.

Our complaints

The chaos and confusion made my husband’s suffering worse, as well as that of his family who were traumatised by what they witnessed, and we later complained to the hospital about what we all had to endure. Much of what we had experienced could have been avoided.

We were convinced that our complaints would lead to at least some improvements in the hospital’s practices and procedures. In their response, however, only in relation to one specific complaint (delay to the delivery of the hospital bed to our home) was there an explanation of the steps that the hospital would take to prevent it happening again. This meant that all the other problems we’d complained about could happen to others. Therefore, we decided to make a submission to the Parliamentary and Health Service Ombudsman (PHSO).

One of the errors in my husband’s discharge summary was to his condition, which was assessed and recorded as ‘moderately frail’ (it should have been ‘terminally ill’). This information bewildered and misled us (causing some family members to delay visiting him, believing he was fitter than he was, for example) and created difficulties for the hospice nurses who came to our home to attend to him. They had prepared to assist someone ‘moderately frail’ and it took them time to adjust and get the necessary equipment and pain relief. Consequently, my husband didn’t receive intravenous morphine until one hour before he died.

As a result of this and the other problems, 34 hours after arriving home my husband died having endured terrible pain and distress in chaotic and undignified conditions, which were devastating for his family to witness.

The hospital had explained the cause of the error to my husband’s discharge summary: it had been auto-populated from his admission data. 

Severity of Injustice

This was duly confirmed as a failing by the PHSO investigation and classified as level 1 in the PHSO’s ‘Severity of Injustice’ scale.[1]

This classification surprised us, because level 1 is assigned to failings considered to cause "annoyance, frustration, worry or inconvenience, typically arising from a single (one-off) incidence of maladministration or service failure".[2] A failing due to auto-population of data is a systemic failing, designed to recur, not intended to be a one-off event.

We were even more surprised and disappointed to learn that when failings are classified as level 1 or level 2 in the PHSO’s six-level ‘Severity of Injustice’ scale, no further action is taken.

When we first complained to the hospital we were encouraged by the information on its website, which expressed a desire to learn from mistakes and improve how they do things in the future.

When we made our submission to the PHSO, we were convinced by the information on their website that our efforts would lead to improvements. The objective of improvement to services is repeated in several places. For example: "If we decide that the organization got things wrong..., we can recommend what it should do about this. We can ask an organization to improve its services to avoid the same things happening again."[3]

The PHSO carried out two investigations into our complaints. The report on the first contained so many errors, misunderstandings and omissions that our caseworker abandoned it and opened a new case. The two investigations, from our first submission to the last communication, took 16 months.

Towards the end of those 16 months, we saw that when a failing is identified, complainants are directed to the ‘Severity of Injustice,’ which focuses not on service improvement but on financial remedy. Failings assigned to level 1 and 2 require no further action. For failings assigned to levels 3–6, financial remedy is considered appropriate. But regardless of level, there are no references to improvement or recommendations, nor does the PHSO appear to publish a comparable document describing the kind of recommendations that might be considered appropriate in relation to failings.

What happens to the objective of improvement?

It is extraordinary to us that the PHSO can identify a failing in a hospital’s practices (and a systemic one too, as in our case) but make no recommendation for the hospital to address it. Unaddressed, such failings can happen again. They may also be complained about and investigated again. What’s the point of a process with such an outcome? Financial compensation is an important consideration, but what happens to the objective of improvement? In the course of our PHSO investigations, it fell by the wayside.

Without improvement to all levels of failings, our NHS will surely be peppered with examples of substandard practices. Patients will continue to suffer avoidable harm. Public money will be wasted on investigations into other patients’ complaints about the same failing.

The thorough review and reform of PHSO procedures called for over a year ago[4] is long overdue to address this bizarre, frustrating and wasteful situation.

We call on hospitals, as well, to review their response to patients’ complaints. If the hospital had responded to our complaint more constructively in 2022, there would have been no need for two PHSO investigations which lasted 16 months and used resources that might have been better deployed elsewhere, and which served only to exacerbate and prolong his family’s trauma.

References

1. Parliamentary and Health Service Ombudsman. Our guidance on financial remedy. https://www.ombudsman.org.uk/sites/default/files/Our-guidance-on-financial-remedy-1.pdf, accessed May 30 2024.
2. Parliamentary and Health Service Ombudsman. Our guidance on financial remedy, p.5. https://www.ombudsman.org.uk/sites/default/files/Our-guidance-on-financial-remedy-1.pdf, accessed May 30 2024.
3. Parliamentary and Health Service Ombudsman. What we can and can’t help with. https://www.ombudsman.org.uk/making-complaint/what-we-can-and-cant-help, accessed May 30 2024.
4. MPs lament NHS and government complaints body’s “lack of ambition” to return to pre-pandemic service delivery levels. https://committees.parliament.uk/work/6930/parliamentary-and-health-service-ombudsman-scrutiny-202122/news/194562/mps-lament-nhs-and-government-complaints-bodys-lack-of-ambition-to-return-to-prepandemic-service-delivery-levels/, accessed May 30 2024.

Following the operation, he was struggling to walk and had a lot of pain in his leg. Two weeks after the surgery, he went back to Accident and Emergency where a doctor questioned whether he might have deep vein thrombosis (DVT). An X-ray and blood tests were carried out but no tests for DVT were done and he was sent home. Two weeks after that, the man had tightness in his chest and fainted. His family called an ambulance, but his heart stopped while on the way to the hospital. Sadly, despite attempts to revive him, he never came round and died in hospital.

The Ombudsman found that doctors at Barking, Havering and Redbridge NHS University Hospitals Trust went against national guidance by not carrying out the relevant tests to rule out DVT. The investigation concluded that if the tests had happened, DVT would have been found and treated, which would have prevented the fatal pulmonary embolism.

Further reading on the hub:

• Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (December 2022, Tim Edwards)
• HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)
• Pulmonary embolism misdiagnosis – a systemic problem (Tim Edwards, December 2022)
• Venous thromboembolism (VTE): deep vein thrombosis and pulmonary embolism (NHS Resolution, May 2023)

In this letter, the Ombudsman Rob Behrens calls for the proposed inquiry into the events at the Countess of Chester Hospital to have statutory status so that it has use of all the legal powers available to get to the truth of what happened. He also reiterates his calls for the recommendations from his recent report on patient safety, Broken trust: making patient safety more than just a promise, to be actioned with urgency. These are:

• A thorough review by the Department of Health and Social Care and NHS England to scrutinise the lack of compliance with the Duty of Candour.
• The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like.
• Conduct a thorough, independent review with cross-party support of NHS leadership, accountability and culture. This review should explore how leadership is accountable, can be regulated and held to the highest standards in the same way as clinicians.

Related reading:

• Lucy Letby verdict, a future inquiry and patient safety – A Patient Safety Learning blog
• Response to PHSO report – Broken trust: making patient safety more than just a promise (Patient Safety Learning, 3 July 2023)

In the report Broken trust: making patient safety more than just a promise, PHSO examines 22 NHS complaints cases where patents died due to avoidable errors.[1] After analysing these cases, they have identified four broad themes of clinical failing leading to avoidable deaths: failure to make the right diagnosis, delays in providing treatment, poor handovers between clinicians and failure to listen to the concerns of patients or their families.

 The report also considers the issue of compounded harm, the additional harm that people experience when interactions following patient safety incidents feel closed and defensive. From their findings, they identify the following scenarios that are likely to contribute to compounded harm:

• failure to be honest when things go wrong
• a lack of support to navigate systems after an incident
• poor-quality investigations
• a failure to respond to complaints in a timely and compassionate way
• inadequate apologies
• unsatisfactory learning responses.

Considering these findings, the PHSO make several recommendations at the end of their report aimed at tackling these issues.

Patient Safety Learning’s reflections

We welcome this new report from the PHSO.

Sadly, the patient safety themes that it raises are all too familiar. Avoidable harm resulting from delays in providing treatment and failing to listen to patient concerns come up time and time again in reports into patient safety incidents. As do failures to respond appropriately after harm occurs, such as poor-quality investigations that do not result in learning or improvement. We see many of the issues that this report raises also feature prominently in recent reports into major patient safety scandals, such as those in East Kent and Shrewsbury and Telford.[2] [3]

Below we share our thoughts specifically on the report’s recommendations for change.

Investigations and PSIRF

The report highlights that while there have been some positive developments in seeking to improve investigations in the NHS, and welcomes the introduction of the new Patient Safety Incident Response Framework (PSIRF), there remains “a gap between the welcome rhetoric in PSIRF guidance documents and the defensive behaviours from some NHS leaders we still see in our casework”.[1]

PHSO note concerns about the additional flexibility that PSIRF offers, suggesting that this may present a risk at Trusts with poor cultures who do not carry out investigations when they should. In response to these concerns, it makes recommendations around the need for close monitoring of the rollout of PSIRF by Integrated Care Boards and Board members who lead on PSIRF in their organisations.

Patient Safety Learning agrees with these recommendations. Although there are many welcomed elements to PSIRF, its success to a large part will depend on having the right organisational leadership and resources to support the transition to this new approach to investigations. We believe that this initiative should be judged on its implementation in supporting culture change and in translating learning from investigations into reduction of avoidable harm.

Duty of candour and support for patients

Duty of candour is intended to ensure that healthcare providers are open and transparent with the public. In legislative terms, it sets specific requirements for organisations to follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong.[4]

PHSO state that from evidence gathered through their casework that they find that this duty is not always implemented as it should be and state they think this requires more attention and monitoring. The report recommends that:

“The Department of Health and Social Care and NHS England should further scrutinise the lack of compliance with duty of candour. They should review the operation of duty of candour to assess its effectiveness and make recommendations for improvement.”[1]

We agree with this recommendation. As part of this reviewing problems with compliance, we believe that there are also broader questions that also need to be addressed concerning how the implementation of this is monitored and what remediation and redress is available to patients and the families when these obligations are not met.

The report also notes that despite a statutory duty for local authorities to commission NHS complaints advocacy, these services can be limited and are often restricted to helping people navigate the NHS complaints process. It recommends that:

“The Department of Health and Social Care should commit to funding further independent advocacy to support harmed patients, families and carers when they raise concerns or seek answers after an incident.”[1]

At Patient Safety Learning, we believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. Access to advocacy services is an essential part of this, helping address the power imbalance between patients and the healthcare system when things go wrong. We fully support this recommendation.

Complex and fragmented patient safety landscape

Discussing the national patient safety picture, the report points to the confusing landscape of patient safety roles and responsibilities that currently exist. It highlights how organisational functions can often overlap, creating confusion over who does what and undermining patient safety leadership. It recommends that:

“The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families”[1]

This is not a new concern. Five years ago, in its report Opening the door to change, the Care Quality Commission (CQC) raised similar issues, noting the lack of clear understanding of how patient safety is organised nationally and who is responsible for what tasks.[5] The Professional Standards Authority for Health and Social Care also pointed this out in their report last year, Safer care for all, stating:

“For too long, individual organisations with different and specific remits have been expected to work together to address workforce and patient and service user safety issues. This approach is structurally flawed as there is generally no accountability for joint working and collaboration; bystander apathy and differing organisational priorities also present significant barriers. Everyone understandably looks at the problem through the lens of their own remit, but no one has the overview.”[6]

Patient Safety Learning agrees with the PHSO’s assessment of this problem. We also highlighted this issue in our report last year, Mind the implementation gap. As stated then, we believe that with the current fragmented approach to patient safety leadership, the Secretary of State for Health and Social Care lacks the levers and means to fundamentally improve our national approach to patient safety.[7]

Workforce strategy

The report also makes a recommendation around the Government producing its long-term workforce strategy and sets out what the PHSO think this document must include, which was subsequently published the day after the report.

Workforce shortages and pressures in the NHS and social care have serious implications for patient safety. We will be looking closely detail of the new NHS Long Term Workforce Plan, in the coming days and weeks from this perspective.[8]

Patient safety as a core purpose of health and social care

In this report, PHSO make the case that patient safety must be a consistent priority over the long term. It recommends that the Government should seek cross-party support for embedding patient safety and the culture and leadership needed to support it as a long-term priority.

We agree with this recommendation. Patient Safety Learning believes that the persistence of avoidable harm is the result of our failure to address the complex systemic causes that underpin it. In our report A Blueprint for Action we set out the need for a transformation in approach to patient safety. This sets out how too often patient safety is typically seen a strategic priority, which in practice will be weighed (and inevitably traded-off) against other priorities.[9] To transform our approach to this it is important patient safety is not just seen as another priority, but as a core purpose of health and care.

This applies to all parts of the system. We need everyone politicians, policymakers, patients, families and communities, clinicians, managers, system and professional regulators, researchers and academics, and health and social care system leaders involved in this effort.

References

1. PHSO, Broken trust: making patient safety more than just a promise, 29 June 2023.
2. Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022.
3. Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, 30 March 2022.
4. Public Health England, Duty of candour, Last updated 5 October 2020.
5. CQC, Opening the door to change: NHS safety culture and the need for transformation, December 2018.
6. Professional Standards Authority for Health and Social Care, Safer Care for All: Solutions from professional regulation and beyond, 6 September 2022.
7. Patient Safety Learning, Mind the implementation gap: the persistence of avoidable harm in the NHS, 7 April 2022.
8. NHS England, NHS Long Term Workforce Plan, 30 June 2023.
9. Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019

PHSO found that the physical harm patients experienced was too often made worse by inadequate, defensive and insensitive responses from NHS organisations when concerns were raised.

Looking at the direct causes of harm, the report identified four broad themes of clinical failings leading to avoidable death:

• failure to make the right diagnosis
• delays in providing treatment
• poor handovers between clinicians
• failure to listen to the concerns of patients or their families.

The report also looked at the further harm – sometimes called compounded harm – that happens when families, who have already experienced the devastating consequences of losing a loved one, try to understand what has happened but are met with a poor response from NHS organisations. It identified several factors that contribute to compounded harm:

• a failure to be honest when things go wrong
• a lack of support to navigate systems after an incident
• poor-quality investigations
• a failure to respond to complaints in a timely and compassionate way
• inadequate apologies
• unsatisfactory learning responses.

PHSO recommendations

1. Accountability for a robust and compassionate response to harm, which supports learning for systems and healing for families.

The Patient Safety Incident Response Framework (PSIRF) offers a new approach to patient safety investigations. It holds great promise but needs to be accompanied by sufficient monitoring and better support for families. 

Recommendation 1

• Integrated care boards, with oversight from NHS England, should closely monitor the impact of the PSIRF to identify any negative consequences of the new flexibility it offers, which gives Trusts more autonomy to decide when a patient safety investigation is needed. This should include paying special attention to the balance of patient safety investigations versus other learning responses in Trusts (or service areas of a Trust) where there are poor Care Quality Commission (CQC) ratings for safety and leadership, or where other national bodies have raised concerns.

Recommendation 2

• As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses This should include where local investigations did not take place, or did not find that things went wrong, but PHSO or another independent oversight body later identified failings.

Recommendation 3

• The Department of Health and Social Care and NHS England should further scrutinise the lack of compliance with duty of candour. They should review the operation of duty of candour to assess its effectiveness and make recommendations for improvement.

Recommendation 4

• The Department of Health and Social Care should commit to funding further independent advocacy to support harmed patients, families and carers when they raise concerns or look for answers after an incident.

2. Evidencing that patient safety is a top Government and NHS priority

NHS leaders and frontline staff need to be in no doubt of the priority placed on patient safety. But patient voice and leadership for patient safety are fractured. Political leaders have created a confusing landscape of organisations, often in knee-jerk reaction to patient safety crisis points. The Healthcare Safety Investigation Branch (HSIB), the Patient Safety Commissioner, PHSO, NHS England, NHS Resolution and at least a dozen different health and care regulators all play important roles in patient safety. But there are significant overlaps in functions, which create uncertainty about who is responsible for what. The Government must consider the case for streamlining some of these functions, for the benefit of people who use the NHS, their families and carers. This is not about reducing investment in patient safety. It is about creating a system that is coherent and easier to navigate, based on evidence and engagement with patients, families, NHS staff and leaders.

Recommendation 5

• The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families.

Patient safety must be a consistent priority over the long term. It must not be subject to changes of emphasis or importance each time there is a new minister or leadership change in the NHS.

Recommendation 6

• The Government should seek cross-party support for commitments to embedding patient safety and the culture and leadership needed to support it as a long-term priority.

It is not possible to prioritise patient safety while avoiding difficult decisions about the workforce the NHS needs. Patient safety will always be at risk in environments that are understaffed and where staff are exhausted and under unsustainable pressure.

Tackling workforce shortages goes beyond political decisions about resourcing. It is about making the NHS a place where people want to work and stay because they feel valued, not just because it is a vocation. We must break down the false dichotomy between the interests of patients and staff, recognising that a system that does not treat its workforce with humanity and compassion will struggle to extend these qualities to patients and families.

PHSO recognise the Government has promised to publish a new NHS workforce strategy. At the time of writing, this is expected ‘shortly’. But for this to properly address the underlying causes of NHS staffing pressures, it needs cross-party consensus. In a sector where it can take nearly two decades to train a consultant doctor, a workforce strategy will only succeed if there is support from across the political spectrum, and far beyond one parliamentary term.

Recommendation 7

 PHSO recommends that the Government should urgently produce its long-awaited long-term workforce strategy, with cross-party support, to increase the numbers entering and staying in the workforce across clinical and non-clinical roles. This strategy must:

• include independent, evidence-based and fully costed projections of future workforce requirements
• include detailed plans for training and recruiting new staff, retaining staff already working in the NHS and attracting those who have left to return
• take account of the mix of different professional skills required, rather than just total numbers in the workforce, and how existing professional skills can be deployed where they are most needed.

Michelle Durkin complained about delays in the diagnosis and treatment of sepsis which led to her husband Stephen’s death. She said that the Trust did not carry out proper observations, put him under the critical care team or transfer him to intensive care quickly enough. She also complained that the Trust did not communicate effectively with her about her husband’s condition which meant she was unable to say goodbye to him.

Findings

The PHSO detailed its findings as follows:

• Our investigation found that the Trust should have detected sepsis earlier than it did. The Trust did not follow its own deteriorating patient policy to observe the patient every four to six hours within the first 48 hours. National guidance on NEWS states that if the NEWS increases, the frequency of observations should also increase. By the time the Trust saw Stephen, his NEWS had increased significantly. It is highly likely that more frequent observations would have detected this deterioration earlier, which would have prompted the Trust to consider how to treat Stephen’s worsening condition.
• We found that even when the Trust did detect the deterioration, it did not react appropriately. According to national guidance, it is essential for patients with a NEWS of seven or more to be assessed by a critical care team. The Trust did not do this until ten hours later, when Stephen’s NEWS was nine.
• We also found that the Trust did not effectively communicate with Michelle about her husband’s condition. When she called the ward, she was not told how unwell he was. If she had been, she could have got to the hospital sooner. We found this would have given her an opportunity to better prepare herself for what was to come, but this option was taken away from her.

Recommendations

Following PHSO recommendations, the Trust has agreed to: 

• write to Michelle to acknowledge the failings identified in our report and apologise for the impact they had on her.
• explain what action it will take to ensure all relevant staff involved in Stephen’s care receive training in sepsis awareness.
• pay Michelle £17,000 in recognition of the injustice she suffered as a result of its failings.

Nutrition and Feeding the patient – contrary to guidance which highlights the importance of high quality nutritional care based on individual assessment of needs with appropriate planning and monitoring, this investigation found the following failings:

• The feeding of porridge contrary to Speech and Language Therapy advice on 3 and 4 December 2016 and offering other foods contrary to advice.
• The recording who fed the patient porridge.
• The identification that the recommended diet was not provided and the taking of appropriate action.
• The recording of foodstuffs in a consistent manner.
• The reporting and recording of adverse incidents in relation to the feeding of porridge on 3 and 4 December 2016.

Communication & Reasonable Adjustments – safe, person centred care is underpinned by effective communication. When caring for a patient with a learning disability communication must be timely and sensitive to the needs of the person and involve the family when appropriate. This is particularly essential in relation to pain management and when a patient is non-verbal. This investigation found the following significant failures:

• Failure to use any kind of pain tool to assess and record the patient’s possible pain or distress. This issue is of particular importance as the patient was unable to verbalise his pain levels.
• Failure to ensure the care of the patient was consistently tailored for a person with dementia and learning disabilities in accordance with GAIN Guidelines.

The investigation also established further failings in relation to:

• A failure to ensure there was a coordinated approach between the Palliative Care and Care of the Elderly teams.
• A lack of coordinated communication between the family, Palliative Care and Care of the Elderly teams.
• The over prescribing of paracetamol to the patient on Ward 3 South due to the inaccurate estimation of the patient’s weight.

The investigation established maladministration in relation to:

• The failure of the Trust to show regard for the patient’s human rights by failing to appropriately support or record the assessment of the patient's possible pain or distress; and to ensure the care of the patient was not consistently tailored for a person with dementia and earning disabilities.
• The failure to report overprescribing of paracetamol in line with the Trust’s ‘Adverse Incident Reporting and Management Policy’, April 2014 and Guidelines for the administration of intravenous (IV) Paracetamol’, December 2014.
• The failure to inform the complainant and her family of the overprescribing of paracetamol in line with the Trust’s ‘Being Open Policy’, February 2015 and it’s ‘Guidelines for the administration of intravenous (IV) Paracetamol’, December 2014.
• The failure to inform the complainant and her family of the overprescribing of paracetamol in line with the Trust’s ‘Being Open Policy’, February 2015.

The poor management of complaints has been highlighted in many of the reports and inquiries that have examined the care of people with a learning disability in hospitals. Opportunities were missed in this complaints handling process to provide the family with empathetic and timely responses which may have helped resolve their concerns locally and prevented them having to use time and energy in approaching the Public Services Ombudsman.

The investigation established failings in the Trust’s handling of the complaint namely:

• The failure to meet with the family prior to completing any investigation.
• The failure to share minutes of the meeting, held on 21 September 2018, with the complainant for comment.
• The delay in issuing minutes of the meeting, held on 21 September 2018, to the complainant.
• The delay in providing a final response to the complainant.
• The failure to provide regular and informative updates to the complainant.
• The failure to ensure coordination between the complaints team and the service area.
• The failure to recognise the sensitivities around arranging a venue for the meeting with the complainant on 21 September 2018.

The investigation did not establish failings in the patient’s care and treatment in relation to:

• The decision to carry out the procedure of oral suctioning on the patient on the night before he died.
• The vitamin drip being administered after the patient was deemed End of Life on 6 December 2016.
• The reducing pain relief without consen.
• The anaesthetics care of the patient on 10 November 2016.

The investigation was unable to make a determination as to whether the vitamin drip was administered prior to the administration of paracetamol on 9 December 2016

Had the investigations been proper at the start, it would not have been necessary for the family to pursue a complaint. Rather, they would, and should, have been provided with clear and honest answers at the outset for the failures in care and would have been spared the hugely difficult process that they have gone through in order to obtain the answers they deserved. As a result, service and investigation improvements were also delayed.