Southampton widow calls on Hampshire NHS for better care

In April, Keith Pead was told he had cancer and not much time left. The 63-year-old engineer decided to spend his last days with his wife Philippa at their home in Bitterne.

“We were told that he would get sleepier and sleepier until he would not wake up,” Philippa, 62, said.

“But it didn’t go like that. He didn’t receive any end-of-life care to make it as peaceful as possible. I know he could not be saved but it did not have to happen like that. It was very traumatic.”

Philippa claimed that official bodies – including the NHS and hospice Mountbatten Hampshire – did not provide the help needed.

NHS bosses have since apologised and said they recognise that the level of care provided “was not to the standard” expected.

Both the NHS and Mountbatten Hampshire stressed that lessons have been learnt and improvements have been made.

However, Philippa is now calling for better end-of-life care and changes to a system she described as “confusing and disorganised”.

Philippa said when Keith’s condition started to deteriorate on April 28 she called Mountbatten Hampshire four times asking for help but was allegedly told there were no beds available.

Philippa and Keith

'Angry and let down'

“Basically there was nothing they could do. We were not offered anything else,” she said.

Philippa, who spent 43 years with Keith, said she felt “angry” and “let down”.

She added: “I don’t know how it works but I assumed that people would come out and see him. Maybe we didn’t make it clear enough. All I knew is that Keith needed help that I could not provide.

"I think they didn’t ask enough questions, I probably didn’t make it clear enough but that is why you can’t triage someone over the phone. You feel like you are just left get on with it on your own. Keith was a very good man who deserved so much better.”

In a report by Mountbatten Hampshire, it was later acknowledged that “a home visit should have been made by the Mountbatten Community Team”  and that “multiple calls from the same person should be a trigger for escalating concerns regarding a patient or family member to the lead nurse”.

Philippa said Keith was “rapidly getting worse” and in his last hours she also called the community nurses managed by Solent NHS  Trust for help.

A letter from Solent NHS Trust told Philippa that “when your telephone call was received, unfortunately questions which should have highlighted red flags or triggers in the urgency of your call, were not asked of you”.

“Keith was frightened, I was very stressed. You would be like that anyway in that situation but it made me feel worse that I could not get the right help for Keith. I feel responsible,” Philippa said.

As well as calls to community nurses, on the morning of April 29, Philippa and a family friend tried to call 111, 999 and Peartree Practice in Southampton.

But Keith died before anyone arrived, Philippa said.

'Human error'

Peartree Practice in Sholing later told Philippa in a letter that “when 111 added Mr Pead to one of our lists it again was missed by the team here, this was down to human error and not checking properly”.

But the practice continued saying that changes were made “so that this list is checked throughout the day at multiple times”.

In another letter Peartree Practice told Philippa “there have been some changes to personnel”.

But it was not confirmed whether anyone was sacked.

Philippa is now calling for better end-of-life care and for all the services provided to be managed by one organisation only.

“The system as it is is confusing because there are too many people in charge,” she added.

The NHS Hampshire, Southampton and Isle of Wight  Clinical Commissioning Group (CCG) said neither the CCG nor the GP practice can comment on individual cases due to a commitment to patient confidentiality.

But the body confirmed there are plans over the next five years to support more people in their homes when they experience a decline in their health within their last years of life.

They also confirmed a 24/7 telephone helpline is in place.

'Key priority'

Stephanie Ramsey, managing director for Southampton at NHS Hampshire, Southampton and Isle of Wight CCG, said: “I offer my heartfelt condolences to Mrs Pead and I am sorry to hear that her husband’s experience fell short of the standards hardworking NHS staff aim to provide.

"Improving and joining up end of life care services in Southampton is a key priority for us and we are committed to making sure people are supported to ensure the last stages of their life happen in the best possible circumstances.”

Jackie Munro, Chief Nurse at Solent NHS Trust, said: “We, along with our healthcare partners in this case, recognise that the level of care and co-ordination of the services during this time was not to the standard we would expect and we are sorry. We have listened to the family’s experiences and undertaken a thorough review alongside other organisations involved in the patient’s care and together we have learnt lessons from this case.”

She stressed that a number of changes including additional training for staff have already been implemented.

Mountbatten Hampshire said its Care Co-ordination Centre was extended to a 24/7 service in May 2021.

The hospice also stressed that several measures have been taken including increasing the capacity of the rapid response nurses, additional staff training and an improved process for identifying urgent patients, including red flags and triggers for escalation.

In a statement Mountbatten Hampshire added: “We would like to say how sorry we are for not providing this gentleman and his family with the care and support they needed at such a difficult time.

“While we are very fortunate to receive hundreds of letters of thanks for the care and support that Mountbatten offers, very occasionally things can go wrong, and whenever that happens, we treat it extremely seriously.

“We liaised with the family member throughout this process, and they have been an important part of helping us learn from this experience so we could redesign our services.

“We understand that there is only one chance to get it right, and we cannot change the experiences of this individual and his family, for which we are very sorry.”

Royston Smith, MP for Southampton Itchen, said measures should be put in place to ensure similar situations do not happen again.

“People should expect that they would get the support they need particularly if they are nursing family at home. That needs to be looked at and acknowledged. No-one should be left alone nursing someone who is dying,” he added.