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Grange Park Surgery (18 013 815a)

Category : Health > General Practice

Decision : Not upheld

Decision date : 10 Sep 2020

The Ombudsman's final decision:

Summary: Mrs X complains about the care her brother, Mr Z, received at the end of his life. The Ombudsmen have found faults in the care provided by Mr Z’s care home and an out of hours GP service. We have found no fault in the actions of Mr Z’s GP practice. The care home and out of hours GP service accept our recommendations. We have therefore completed our investigation.

The complaint

  1. The complainant, whom I shall call Mrs X, complains about poor quality care given to her late brother, Mr Z, while in Burley Hall Care Home at the end of his life in August 2018. In particular, Mrs X complains that:
    • Burley Hall Care Home (the Home, a part of Bupa Care Homes (GL) Limited) and Grange Park Surgery (the GP Practice) failed to arrange anticipatory end of life medication to control Mr Z’s pain before he entered the last days of his life; and
    • Local Care Direct (LCD), an out of hours GP service provider, delayed issuing an emergency prescription for morphine.
  2. Mrs X says that as a result:
    • Mr Z suffered unnecessarily in the last hours of his life because of pain that should have been controlled by medication;
    • Mrs X suffered avoidable distress when witnessing this; and
    • Mrs X had to go to unnecessary time and trouble in trying to get the medication out of hours, rather than being able to spend uninterrupted time with her brother while he was dying.

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The Ombudsmen’s role and powers

  1. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
  2. The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. We decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. Where something has gone wrong we refer to those actions as ‘fault’. (Local Government Act 1974, sections 34B, and 34C, as amended)
  3. The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services. We use the word ‘fault’ to refer to these. If there has been fault, the Health Service Ombudsman considers whether it has caused injustice or hardship. (Health Service Commissioners Act 1993, section 3(1))
  4. If the actions of a health and social care provider have caused injustice, the Ombudsmen may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
  5. The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
  6. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
  7. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

  1. I have considered information Mrs X has provided in writing and by telephone. I have also considered written information from Bupa, LCD and the GP Practice.
  2. I have sought clinical advice from a GP with experience of providing palliative care.
  3. Mrs X, Bupa, LCD and the GP Practice have had an opportunity to comment on a draft version of this decision. I have taken their comments into account when reaching a final decision.
  4. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Background summary

  1. Mr Z was in his 70s and had bowel cancer that had spread to other parts of his body and was not expected to recover from this. After a stay in hospital, he moved to the Home on 10 August 2018 to be nearer his family. The expectation was that he would stay there until the end of his life. Mr Z had capacity to make his own decisions around care, treatment and where he lived.
  2. While Mr Z lived at the Home, he was registered with the GP Practice. LCD provided an out of hours GP service.
  3. A GP from the GP Practice saw Mr Z on 15 and 23 August but did not prescribe end of life (EOL) medication in advance.
  4. Mr Z’s health declined significantly in the evening of 25 August 2018. The Home contacted LCD in the evening and night of 25/26 August 2018 to request EOL medication to ease Mr Z’s pain. Mr Z did not get pain relief until 06.20 in the morning of 26 August 2018. He received more pain relief at about 14.00 on 26 August 2018. Mr Z he died at the Home later that day.

BUPA – the Home’s management of end of life medication

  1. Mrs X says that the Home assured her at the outset that it would arrange EOL medication for her brother and this was one of the reasons she chose the Home for Mr Z’s last stage of life. I have found no documentary record of this conversation.
  2. The available documentary records show that when he first moved into the Home, although Mr Z had a terminal illness,
    • there was no indication that he was in the last few days or hours of his life;
    • Mr Z was not keen to discuss the likelihood that he was approaching the end of his life.
  3. At this point, it would have been for the GP Practice to consider and, if appropriate, discuss the need for anticipatory EOL medication with Mr Z. I will address the GP Practice’s role below. There was no fault in the way the Home dealt with Mr Z’s need for anticipatory EOL medication between 10 and 24 August 2018. This is because
    • Mr Z did not want to discuss his end of life needs at the time and he had the capacity to make decisions about his own care; and
    • we would not expect the Home to ask the GP Practice to prescribe anticipatory EOL medication, unless this was something that Mr Z had asked the Home to do on his behalf.
  4. The available evidence indicates Mr Z’s health deteriorated significantly during the day of 25 August 2018. This was a Saturday. A statement from a nurse on the night shift for 25/26 August 2018 says that:
    • a day shift nurse had informed her at handover time that Mr Z’s health deteriorated significantly during the day and that he had a prescription for anticipatory EOL medication;
    • by about 22.45 Mr Z became distressed and said he was in so much pain that he did not think paracetamol would be adequate; and
    • at that point, the night shift nurse discovered that Mr Z did not have anticipatory EOL medication in place and contacted the out of hours service for help.
  5. Mr Z had paracetamol as this was the only pain relief available. The Home’s records indicate this was not enough to control his pain. He eventually received a strong pain relief injection at 06.20 on 26 August 2018.
  6. The Nursing & Midwifery Council (NMC) has issued professional standards of practice for nurses, called The Code. This says nurses must:
    • recognise and respond compassionately to the needs of those who are in the last few days and hours of life;
    • accurately identify, observe and assess signs of worsening health in the person receiving care; and
    • make a timely referral to another practitioner when any action, care or treatment is required.
  7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulations) set out the fundamental standards those registered to provide care services must achieve. The CQC has issued guidance on how to meet the fundamental standards which care must never fall below. Regulation 9 says that care providers must provide appropriate care and treatment that meets people’s needs and is in line with their wishes. Regulation 12 says that care providers must provide care and treatment in a safe way.
  8. I consider that
    • the Home was aware that Mr Z had a terminal illness and that he had deteriorated significantly during the day of 25 August 2018;
    • the Home should have checked Mr Z’s records, including those for prescribed medication, and offered to contact a GP during the day of 25 August 2018; and
    • failing to do so was contrary to NMC’s The Code and Regulations 9 and 12 and was fault.
  9. As 25 August was a Saturday, the referral would likely have been to an out of hours GP service. We cannot say now whether Mr Z would have agreed to discuss end of life medication with a GP at that time. However, there was a missed opportunity for a GP to review Mr Z’s condition and possibly prescribe anticipatory EOL medication before his pain escalated in the night.
  10. As a result, Mrs X is left with uncertainty about whether her brother could have had anticipatory EOL medication in place before his pain deteriorated in the night. To remedy this, the Home should provide Mrs X with a written apology acknowledging the fault we have identified and its impact.
  11. In response to Mrs X’s complaint, the Home has already explained that it will be learning from what happened by ensuring that staff:
    • are aware of how quickly people can decline; and
    • where appropriate ask that anticipatory EOL medication is put in place in advance and, if necessary, challenge GPs about this.
  12. This is an appropriate way to prevent similar problems happening again, as long as the Home can provide evidence that it has implemented this learning.

GP Practice – end of life medication

Summary of key events

  1. Before August 2018, Mr Z lived in another part of the country and was registered with a different GP. When he moved to the Home on 10 August 2018, he also registered with the GP Practice. His old GP transferred some of his medical records immediately, but the GP Practice did not have access to all his old records straight away. The GP Practice was, however, aware that he had bowel cancer that had spread to other parts of his body and was approaching the end of his life.
  2. A GP from the GP Practice (GP1) saw Mr Z on 15 August 2018 in the Home. GP1:
    • noted staff were concerned about Mr Z’s mood but Mr Z felt he was coping fine;
    • reviewed Mr Z’s medication;
    • considered that Mr Z was in the end stage of life but expected to live for weeks; and
    • referred Mr Z to a specialist palliative care telephone service and a specialist palliative care team based at a local hospital. Palliative care is care for an illness that cannot be cured and that makes a patient as comfortable as possible by managing physical symptoms and offering psychological and social support.
  3. The GP Practice has explained that part of GP1’s reasoning for referring Mr Z to the palliative care team was Mr Z’s reluctance to discuss end of life care with the GP and Home staff. As well as seeing Mr Z, GP1 completed an Electronic Palliative Care Co-ordination System (EPaCCS) record on 15 August 2018 and updated it on 17 August.
  4. When referring Mr Z for specialist palliative care services, GP1 noted that:
    • Mr Z was reluctant to talk about his illness other than symptoms such as nausea and vomiting;
    • although Mr Z consented to the referral he may refuse to see the palliative care team; and
    • Mr Z was still having some chemotherapy and the GP Practice did not have full information from his cancer specialist, but Mr Z was believed to be approaching the end of his life.
  5. Between 21 and 23 August, the palliative care nurses tried to contact Mr Z by phone four times to arrange an appointment but were not able to reach him.
  6. Records indicate that Mr Z:
    • had a hospital oncology (specialist cancer medicine) appointment booked for 22 August, with a further appointment arranged for the following week; and
    • started taking chemotherapy medication.
  7. GP1 saw Mr Z again on 23 August in the Home. GP1 noted that Mr Z continued to experience periods of vomiting and reviewed his medication. GP1 also discussed a wheelchair and the referral to palliative care with Mr Z.


  1. The General Medical Council (GMC) has issued guidance titled “Treatment and care towards the end of life: good practice in decision making”. It says that doctors “must plan ahead as much as possible to ensure timely access to safe, effective care and continuity in its delivery to meet the patient’s needs”. There is no guidance which says exactly when GPs should prescribe anticipatory EOL medication. Typically, it is prescribed when a GP considers that the patient is likely to need this medication in the next few days to small number of weeks. This depends on the GP’s judgement.
  2. The records of the GP appointments of 15 and 23 August do not indicate that
    Mr Z needed anticipatory EOL medication at that time. He did not report any symptoms other than nausea, vomiting and reflux. He was still under the care of the oncology department, taking chemotherapy medication and had a follow-up oncology appointment the week after 23 August.
  3. There were potential opportunities for the GP Practice to prescribe anticipatory EOL medication between 15 and 23 August 2018. However, Mr Z had capacity to make decisions about his care and was reluctant to discuss end of life care with GP1. The GP Practice could not have prescribed this medication without Mr Z’s consent. Now that we know how Mr Z’s health declined on 25 August, with hindsight we could say that it would have been best for Mr Z to have anticipatory EOL medication in place before 25 August. However, the GP Practice did not act with fault at the time, when it did not prescribe this medication.
  4. The GP Practice has also shown it has learnt from what happened by doing the following:
    • holding a formal Significant Event Analysis meeting which resulted in a change in how GPs discuss anticipatory EOL medication with patients;
    • conducting an audit of when it prescribes anticipatory EOL medication and checking whether it could and should have been prescribed earlier; and
    • involving the palliative care nurse in regular monthly meetings discussing patients in the end stages of life.

LCD – delay in issuing emergency prescription for morphine

Summary of key events

  1. On Saturday 25 August 2018, Mr Z became very unwell. Mrs X came to stay with him that night. The available records from the Home, the GP Practice and LCD indicate that the following happened:
    • at 22.45, Mrs X alerted the nurse that Mr Z was in pain. The nurse assessed him and considered he appeared to be in considerable pain, more than would be resolved by paracetamol;
    • the nurse checked Mr X’s records and discovered that he did not have anticipatory EOL medication in place;
    • at 23:10 the nurse contacted the specialist palliative care telephone line and requested that a GP visit Mr Z urgently to prescribe the medication, so Mr Z could receive strong pain relief. This request was passed on to the out of hours GP service;
    • an out of hours GP (GP2) saw Mr Z at 01.40 of 26 August 2018. GP2 prescribed morphine to reduce pain, midazolam to reduce agitation, cyclizine to reduce nausea and vomiting, and buscopan to reduce secretions. These medications are to make a person more comfortable in their last few hours. The Home would need to go to a pharmacy the next day to get these medicines. Mr Z received an injection of midazolam but could not have any morphine at the time as there was none in GP2’s vehicle;
    • the nurse noted at 05.00 that Mr Z drifted in and out of sleep but could not settle fully and appeared to be in pain. He could not take oral painkillers such as paracetamol because he was vomiting. The nurse contacted the out of hours GP service again and asked them if a GP could visit to administer morphine;
    • GP2 visited Mr Z at 06.20 and Mr Z then received injections of diamorphine (a pain medication that is stronger than morphine) and cyclizine;
    • the Home contacted the out of hours GP service again at around 09.30, stating the pharmacy had rejected the prescription for morphine as it was incorrectly written. The Home reported Mr Z was in a lot of pain at this time;
    • an out of hours GP (GP3) visited the Home again at about 11.10 and re-issued the prescription. The pharmacy contacted the Home at 11.45 to advise it that the prescription for morphine was still incorrect because it did not include instructions on how to give the medication;
    • GP3 re-issued the prescription for morphine straight to the pharmacy at about midday; and
    • the Home received the morphine at about 14.00 and a nurse gave Mr Z an injection of morphine at 14.15.


  1. LCD has accepted the following faults in providing Mr Z’s care:
    • its GP vehicles should carry a stock of anticipatory medicines to avoid delay in treatment, but there was no morphine available during the first visit to Mr Z; and
    • the first two prescriptions were not issued in accordance with its internal guidance and the British National Formulary guidance on prescribing controlled medicines (medicines such as morphine which are subject to strict legal controls).
  2. LCD says that its computer system crashed midway through GP3 issuing the second prescription which. It has concluded this led to the second prescription not having instructions.
  3. I consider that:
    • these faults led to Mr Z suffering avoidable pain in the last hours of his life;
    • had the faults not happened, it is likely that Mr Z would have had access to effective pain relief from about 01.45 of 26 August 2018;
    • instead, he had to wait until 06.20 that morning to receive some pain relief; and
    • although he was reported to be in pain about three hours later, he did not receive any more pain relief until nearly eight hours later; and
    • Mrs X has suffered the avoidable distress of seeing her brother in pain, which could have been relieved.
  4. LCD has offered its sincere apologies to Mrs X for what happened and agreed to pay Mrs X £250 in recognition of her avoidable distress.
  5. LCD has also done the following to prevent the same problem happening again:
    • requested that all its visiting doctors carry anticipatory medicines at all times to prevent delay in treatment;
    • met with the GPs involved to review the care provided to Mr Z and the impact of faults on Mr Z and his family;
    • ensured its GPs receive appropriate information about EOL medication during their induction; and
    • worked on its computer system so instructions for use with medication are automatically added to prescriptions rather than GPs having to add them manually.
  6. I consider that, in taking these steps, LCD has taken appropriate action to prevent similar problems recurring.

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Agreed actions


  1. Within 1 month of the date of my final decision, BUPA will:
    • send a written letter of apology to Mrs X acknowledging the problems identified in this decision and their impact on her; and
    • send the Ombudsmen evidence that it has implemented the actions set out in paragraph 28.


  1. Within 1 month of the date of my final decision, LCD will send a written letter of apology to Mrs X acknowledging the problems identified in this decision and their impact on her.
  2. Within 3 months of the date of my final decision, LCD will pay Mrs X £250 in recognition of her avoidable distress.

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Final decision

  1. There was fault by the Home and LCD, leading to avoidable pain for Mr Z and avoidable distress for Mrs X. There was no fault by the GP Practice. LCD and the Home accept my recommendations, so I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman

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