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Calderdale & Huddersfield NHS Foundation Trust (20 003 435a)

Category : Health > Hospital acute services

Decision : Closed after initial enquiries

Decision date : 14 Oct 2020

The Ombudsman's final decision:

Summary: The Ombudsman will not investigate Ms X’s complaint. This is because the Parliamentary and Health Service Ombudsman is better placed to consider her complaint.

The complaint

  1. The complainant, Ms X, says Calderdale and Huddersfield NHS Foundation Trust (the Trust) discharged her mother, Mrs Y, with no care plan. Also, it did not refer her for community palliative care, despite agreeing to do so.
  2. The Trust and district nurses (who worked for Locala Community Partnership CIC) poorly communicated end of life care to Mrs Y and the family, including anticipatory medications. The family were under the impression Mrs Y had weeks to live after 2 May, rather than days.
  3. The district nurses administered diamorphine against Mrs Y’s wishes.
  4. The district nurses were uncaring and made racist assumptions about the family. That restricted the treatment choices in the community, which impacted the quality of her care.
  5. Ms X says events were distressing for the family to witness. Also, she has had problems sleeping.
  6. Ms X would like the organisations to carry out service improvements and training to avoid similar fault happening to others.

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The Ombudsman’s role and powers

  1. The Ombudsman provide a free service but must use public money carefully. They may decide not to start or continue with an investigation if they believe there is another body better placed to consider this complaint. (Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

  1. I have considered information Ms X has provided in writing and by telephone. Ms X had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

  1. Mrs Y suffered with breast and bone cancer.
  2. In late April 2018 Mrs Y had breathing difficulties, so the Trust admitted her. The Trust fitted a drain in Mrs Y’s stomach to drain excess fluid. The drain reduced swelling in her stomach. Ms X said during the admission the Trust told Mrs Y (and the family) she most likely had weeks to live. The Trust agreed to discharge Mrs Y home on 2 May with an inhaler and anticipatory medications (to help manage symptoms, including pain, at the end of someone’s life).
  3. At home, Mrs Y built up more fluid in her stomach. An out of hours GP prescribed diamorphine, but Mrs Y did not want to take it. District nurses later administered the diamorphine to Mrs Y. Another out of hours GP later asked Kirklees Metropolitan Borough Council (the Council) to support Mrs Y. The Council told the family it was not the right organisation to provide end of life support and referred them to Locala. Locala later said it was not responsible for providing community palliative care to Mrs Y.
  4. On 8 May, the family felt Mrs Y’s condition was worsening, so the Trust readmitted her. Ms X said the Trust told the family Mrs Y only had a few hours to live. Therefore, as Mrs Y wished to be at home at the end of her life, the Trust discharged her later that day. Mrs Y died the next day.
  5. The Ombudsman will not investigate this complaint.
  6. The Council’s role in Mrs Y’s care was limited. Ms X’s complaint (in paragraph one) is fundamentally that no one provided community palliative care to Mrs Y after 2 May 2018. The Council could not provide that.
  7. I recognise there was confusion between the out of hours GP, Locala and the Council about whom should provide community palliative care to Mrs Y. However, the Trust was responsible for making that referral before it discharged Mrs Y on 2 May. It recognised that was a missed opportunity.
  8. Also, Ms X’s complaints in paragraphs two to four (above) are solely about the actions of the NHS. Therefore, I consider PHSO is better placed to consider Ms X’s complaint.

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Final decision

  1. The Ombudsman should not investigate this complaint. This is because PHSO is better placed to consider Ms X’s complaint.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman

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