Decision Report 202006034

Summary

C complained about the end of life care that their partner (A) received at home from district nursing services during the final weeks of their life.

C complained that the nurses did not listen to their concerns about A’s deteriorating condition, that A’s condition was not adequately assessed and managed, and that they were not included in discussions about A’s care. C considered that there were missed opportunities to admit A for earlier hospice care.

We took independent advice from an advanced nursing practitioner. We found that the care provided to A was generally in line with recognised practice for end of life care, with review and prompt action around pain control and symptom management. However, we found that there were significant gaps in communication and clinical assessment which impacted on the care delivered to A.

While the nurses recorded C’s reported changes in A’s condition, this did not appear to have prompted any specific action or investigations. We found that there was a lack of clinical examination, and a failure to check and act upon C’s reports of excessive fluid in A’s legs. The board acknowledged that there was a failure to monitor A’s baseline observations when they began to deteriorate, and we found it concerning that this did not happen. The board also accepted that communication with A and C could have been better managed and they committed to raising this with staff. As A’s main carer, we noted that C’s views should have been central to care planning and to ensuring that the care being provided remained suitable as A’s condition changed. We found that there was an unreasonable failure to act upon C’s concerns and consider whether a need for hospice care was indicated. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients receiving end of life care at home should be appropriately assessed and monitored in line with their symptoms and any deterioration acted on. Patients and their carers should be communicated with effectively and their views appropriately taken into account.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.