District nurses failed to provide reasonable care and support

Mr V was terminally ill with cancer and wanted to die at home. His GP referred him to the District Nurse Service for support with this, but the Service overlooked the referral. When Mr V deteriorated quickly on a Sunday evening, his wife, Mrs V, phoned the Service several times, but got no answer and could only leave messages on an answer machine.

District nurses came the following day and agreed to fast‑track a referral for carers to come quickly. But there was some confusion and that did not happen as planned. The district nurses declined Mrs V's request that they phone the GP from her home to seek authorisation to increase the dosage of pain relief in Mr V's syringe driver. They did not explain that they needed written authorisation to do this. They also declined to fit an incontinence pad on Mr V, saying the carers would do this. It was only when Mrs V's daughter contacted their MP for help that everything was put correctly in place.

The carers then provided what Mrs V described as 'superb' care until Mr V died the next day.

What we found

The care provided by the Trust was not in line with recognised quality standards and established good practice. Mrs V was given wrong information about who would provide the carers, which caused confusion and anxiety when she tried to follow up the referral. The Trust failed to explain to Mrs V the situation over the medication for the syringe driver. This caused needless anxiety, distress and suffering to her and her husband. Mrs V described herself as feeling 'abandoned and out of her depth'.

Putting it right

The Trust acknowledged and apologised for its failings. It also put a plan in place to prevent these things happening again.