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Health Ombudsman Identifies Failings in End of Life Care

Approximately half a million people die in England each year, of which three quarters of whom are expected due to terminal illnesses. Many of these people are given “end of life” or “palliative” care. However, in a recent damning report the Parliamentary and Health Service Ombudsman has warned that too many people are dying without dignity.

Parliamentary and Health Service Ombudsman

The Parliamentary and Health Service Ombudsman is an independent service, set up by Parliament to investigate complaints from individuals who feel they have been treated unfairly or received poor services from government departments, other public organisations and the NHS in England. The Ombudsman makes the final decision on complaints and ensures that lessons are learned to ensure public services improve.

Report - “Dying without Dignity”

The Ombudsman’s latest report entitled “Dying without Dignity” examined end of life care - a consistent theme in their casework. Ombudsman, Dame Julie Mellor, identifies in the report some of the worst cases investigated by the watchdog in the past four years, where patients’ suffering could have been avoided or lessened with the right care and treatment as they approached the end of their lives.

The report examines a few horrific anonymised examples where the patient and their relatives experienced unnecessary suffering. Examples include a 60 year old man who suffered pain for four months because his GP did not assess the care he needed despite it being clear that he was going to die; a 74-year-old man whose distress and pain was not relieved in hospital in his last hours, and a dying 29-year-old man with widespread cancer who suffered for more than 11 distressing hours before receiving effective pain relief.

End of life care is a consistent and recurring theme in the ombudsman’s casework and the report identifies six key issues:

  1. Failure to recognise that patients are dying and to respond to their needs:
  2. Poor symptom control;
  3. Poor communication;
  4. Inadequate out-of-hours services;
  5. Poor care planning;
  6. Delays in diagnosis and referral for treatment.


Ombudsman, Dame Julie Mellor told BBC Radio 4 that the report made “very harrowing reading” and urged the NHS to learn lessons from the report to prevent similar failures from happening again.

Professor Sir Mike Richards, the chief inspector of hospitals at the Care Quality Commission, said that although there were examples of great care for the dying, delivered with sensitivity and compassion, the CQC “has also found instances where end of life care has not been given high enough priority within a trust.”

A Department of Health spokesman said, “These are appalling cases – everyone deserves good quality care at the end of their lives.

“Doctors and nurses must involve patients and their families in decisions about their care, regularly review their treatment and share patients’ choices to make sure their wishes are respected.

“NHS England is working on making these priorities a reality for everyone who needs end of life care.”

The Parliamentary and Health Service Ombudsman has investigated 265 complaints about end of life care in the past four years, upholding just over half of them. The Ombudsman is committed to ensuring that the complaints ultimately make a difference so that the quality of end of life care across the country improves.

We hope to see a sea change in the way that end of life care is delivered in the hope that every person who passes away in a medical setting receives the best care and is made as comfortable as possible.

Samuel Flack is a Paralegal in the Clinical Negligence department at Slater and Gordon Lawyers UK.

Our Clinical Negligence Solicitors can provide immediate legal representation and rehabilitation support anywhere in England, Scotland and Wales and offer hospital and home visits for people who cannot attend one of our offices.
Call us for a free consultation on 0800 916 9049 or contact us online.

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