BackThe Parliamentary and Health Service Ombudsman makes final decisions on complaints about the NHS in England, including where there is a dispute about what happened. The Ombudsman service identified a range of issues with end of life care from its casework. The insight from its casework revealed:
- Poor communication with families losing the chance to say goodbye to their loved ones,
- Poor planning leading to uncoordinated care,
- Inadequate out-of-hours services and
- Poor pain management meaning that people spend their last days in pain when it can be avoided.
The Ombudsman service looked at investigations it had completed about end of life care - the care and treatment someone has received in the last 12 months of their life – to highlight where things are going wrong to help ensure improvements are made. It looked at complaints it had investigated in end of life care, up and down the country, across the NHS, from GP practices to hospitals and mental health trusts, to identify the issues it sees the most often.
The report includes summaries of cases the Ombudsman service has investigated about end of life care. They include:
A 74-year-old cancer patient who spent his last days in avoidable pain. He was subjected to 14 unnecessary attempts to reinsert a drip, which caused him further pain and discomfort in his final hours.
A mother who was forced to call an A&E doctor to administer more pain relief to her 29-year-old son who was in a hospital's palliative care unit. The investigation found that he experienced unnecessary pain and distress for more than 11 hours because the on-call doctors did not respond to a request to review his pain medication, and this issue was never escalated to senior staff.
A family who watched their loved one suffer because the palliative care team were not available to help control the woman's distressing symptoms in the last hours of her life. The 56-year-old woman had epilepsy and suffered a cardiac arrest.
Parliamentary and Health Service Ombudsman Julie Mellor said: “Our casework shows that too many people are dying without dignity. This report highlights the impact on patients and their loved ones, when the care and treatment of people nearing the end of their lives, falls short. Our investigations have found that patients have spent their last days in unnecessary pain, people have wrongly been denied their wish to die at home and that poor communication between NHS staff and families has meant that people were unable to say goodbye to their loved ones. We are publishing this insight so the NHS can consider the lessons to help prevent similar cases from happening again.”
The report identifies six key themes that the Ombudsman service regularly sees in its end of life care casework. These are:
Not recognising that people are dying or responding to their needs
- Poor symptom control
- Poor communication
- Inadequate out-of-hours services
- Poor care planning
- Delays in diagnosis and referrals for treatment
The Parliamentary and Health Service Ombudsman makes final decisions on disputes about complaints between individuals and the NHS in England, and UK government departments and their agencies.
Source: Parliamentary and Health Service Ombudsman, UK
