The Ombudsman's final decision:
Summary: The Ombudsmen found no fault by a Council, an NHS Trust and a Mental Health Trust about the care they arranged or provided to someone with Parkinson’s Disease following several hospital admissions. The Ombudsmen found fault by a GP Practice in its assessment of a patient and in its recording about medication reviews. However, the faults did not cause the patient harm and there was no fault with the clinical care. The Ombudsmen made recommendations to the Practice to apologise to the patient’s family for the distress caused by the faults and to review this case and make service improvements.
- Mr Q complains about aspects of the care and treatment provided to his late brother, Mr R, by East Sussex County Council (the Council), East Sussex Healthcare NHS Trust (the Trust), Sussex Partnership NHS Foundation Trust (the Mental Health Trust), Warrior Square Surgery (the Practice) and Hastings and Rother Clinical Commissioning Group (the CCG) in 2013 and 2014.
- In particular Mr Q complains that:
- The Council:
- Replaced Mr R’s previously agreed healthcare services with inappropriate social care services. This meant Mr R did not receive the healthcare he needed and resulted in a significant deterioration in his health;
- Failed to liaise with the Practice about Mr R’s admission to, and discharge from, hospital in 2013;
- Intervened to prevent Mr R’s transfer to a care home in 2013;
- Failed to identify the symptoms that led to Mr R’s death.
- Failed to provide Mr R with healthcare services agreed following his discharge from hospital in July 2013. This included a failure to monitor and manage Mr R’s clinical trial medication;
- Discharged Mr R from a unit prematurely in September 2013, without having completed an adequate risk assessment. Mr Q also says the Trust failed to provide Mr R with adequate community nursing support following his discharge;
- Transferred Mr R to a mental health unit that could not meet his physical health needs;
- Failed to provide adequate community nursing support to Mr R following his further discharge in November 2013. Mr Q says this meant the Trust failed to identify the symptoms that led to Mr R’s death;
- Refused to address his complaint.
- Provided inadequate physical health care to Mr R on the mental health unit. Specifically, Mr Q says the Mental Health Trust failed to provide appropriate care for his brother’s Parkinson’s Disease;
- Failed to transfer Mr R back to a medical ward so he could receive appropriate treatment.
- Failed to monitor and manage Mr R’s medication following his discharge from hospital in July 2013;
- Failed to identify Mr R as an adult at risk;
- Failed to liaise with other agencies involved in Mr R’s care about his medication;
- Failed to treat Mr R’s kidney stones;
- Failed to examine Mr R when social care staff reported that he may be suffering from Deep Vein Thrombosis (DVT). Mr Q says the failure to identify DVT meant no action was taken that could have prevented thromboembolism;
- Failed to take into account Mr R’s medical history or recognise how seriously ill he was when a GP saw him a day before he died.
- Failed to accurately assess Mr R’s care needs, resulting in him not receiving Continuing Healthcare (CHC) funding.
The Ombudsmen’s role and powers
- The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
- If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
- The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
- When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened.
- If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
How I considered this complaint
- In reaching this decision, I took account of the information Mr Q provided to the Ombudsmen. I made enquiries of the Council, the Trust, the Mental Health Trust, the Practice and the CCG and took account of the documents and comments they provided, including relevant medical and care records for Mr R. I also sought clinical advice from two of the Ombudsmen’s professional advisers; a consultant psychiatrist and a general practitioner with relevant experience of the maters complained about.
What I found
- At the time of the events complained about, section 47 of the NHS and Community Care Act 1990 placed a duty on councils to conduct an assessment when an adult appeared to need community care services. The assessment would be generally be carried out by social workers and/or occupational therapists, although this was not mandatory.
- Department of Health guidance Fairer Charging Policies for Home Care and other non-residential Social Services (June 2013) said councils could charge for non‑residential care charges. Councils could take account of savings when deciding if a service user should contribute to their care charges. A financial assessment would determine how much an individual should contribute to their social care costs.
- At the time, the Council would not normally contribute to the cost of non‑residential care for someone with over £23,250 in savings.
Joint Community Rehabilitation service
- Joint Community Rehabilitation (JCR) is a rehabilitation and reablement service. Occupational therapists from both health and adult social care backgrounds work with physiotherapists and support workers to provide goal-based reablement and rehabilitation. The aim is to help people restore or minimise loss of function and maximise independence and/or wellbeing, often after discharge from hospital.
- The Department of Health’s National Framework for NHS Continuing Healthcare and NHS‑funded Nursing Care (November 2012 (Revised)) (the National Framework) is the key guidance about Continuing Healthcare. It states that where an individual is eligible for Continuing Healthcare funding the CCG is responsible for care planning, commissioning services and case management.
- CHC is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. For most people who may be eligible for CHC, the first step in assessment is for a health or social care professional to complete a CHC Checklist. The threshold for meeting the CHC Checklist is set low.
- If the completed CHC Checklist indicates the person may be eligible for CHC, the next step is a full multidisciplinary assessment. This assessment is completed using a decision support tool (DST). The DST is a record of the relevant evidence and decision-making. The DST makes a recommendation about whether a person is eligible for CHC.
- If, after a full multidisciplinary assessment and DST, a person disagrees with the CCG’s decision that they are not eligible for CHC or nursing care, they can ask the CCG to review its decision. If they disagree with the outcome of the review, they can appeal to an Independent Review Panel (IRP) organised by NHS England. The third stage is to refer the case to the Health Service Ombudsman for independent investigation.
Mental Capacity Act
- The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. Section 42 of the MCA provides for a Code of Practice (the Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
- Both the MCA and the Code start by presuming individuals have capacity unless there is proof to the contrary. The Code says people who make unwise decisions should not automatically be treated as not being able to make decisions. Someone can have capacity and still make unwise decisions.
Treatment of chest infections
- The National Institute for Health and Care Excellence (NICE) issued a Clinical Knowledge Summary on Chest Infections for adults. This says if a person has clinical symptoms and signs suggestive of community acquired pneumonia, clinicians should assess the severity of the illness using the CRB-65 score for mortality risk.
- The score is calculated by giving one point for each of the following:
- Confusion (new disorientation in person, place, or time).
- Raised respiratory rate (30 breaths per minute or more).
- Low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg).
- Age 65 years or more.
- Wells scores are a clinical prediction rule for estimating the probability of DVT and pulmonary embolism. The British Thoracic Society published guidelines in 2009 – ‘Guidelines for the Management of Community Acquired Pneumonia in Adults’. At the time of the events complained about, this recommended the use of the two‑level Wells scores to aid diagnosis of pulmonary embolism or DVT. Risk factors are compared and given a score, with a total of 2 points or more meaning DVT is likely. More recent guidance published by NICE in December 2014 (CG144 – ‘Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing’) references the British Thoracic Society’s guidance and advises the same approach.
INR - International normalized ratio
- INR is a system established by the World Health Organization (WHO) and the International Committee on Thrombosis and Hemostasis for reporting the results of blood coagulation (clotting) tests. It is used to monitor the effectiveness of warfarin medication (anticoagulant) and adjust the dose.
- A D-dimer test detects pieces of blood clot that have been broken down and are loose in the bloodstream. The larger the number of fragments found, the more likely it is the individual has a blood clot in their vein.
- Prucalopride is a medication used to restore normal bowel movements. At the time of this complaint, this medication was not licensed for use in men.
- The complaints procedure for councils and NHS organisations is set out in the Local Authority Social Services and NHS Complaints (England) Regulations 2009 (the ‘Complaints Regulations’). This says a complaint must be made no later than 12 months after the date the events complained about happened or from when the complainant became aware of the matters they are complaining about. Organisations can still investigate if the complainant had good reasons for not making the complaint within the time limit and it is still possible to investigate the complaint effectively and fairly.
- Mr R was diagnosed with Parkinson’s Disease in 1999.
- He was under a specialist at the National Hospital for Neurology and Neurosurgery, part of University College London Hospitals NHS Foundation Trust (UCLH). In March 2011 a doctor at UCLH noted Mr R’s Parkinson’s Disease medication, Stalevo, was not always working. UCLH asked the Parkinson’s Disease nurse based at Conquest Hospital, part of the Trust, to discuss using a different Parkinson’s Disease medication (apomorphine) with Mr R.
- In early 2013 Mr R’s condition deteriorated. He had difficulties with severe abdominal bloating, which he felt improved with Stalevo. On 14 February 2013 Mr R’s GP wrote to UCLH. The GP said Mr R was no longer seeing the Parkinson’s Disease nurse at Conquest Hospital after a disagreement over therapy, and asked for UCLH to help.
- In May 2013 Mr R was seen at UCLH. The doctor noted he was struggling at home, and needed involvement of a dietician, physiotherapist, occupational therapist, and review by a neuro-gastroenterologist. The doctor wrote to his GP about the appointment and asked the GP to refer him to the dental hospital, to the local occupational therapy (OT) service and to social services for urgent home assessment. The doctor suggested a complete social care package including OT assessment and carers to help Mr R with his domestic needs.
- On 17 June 2013 Mr R was admitted to UCLH for assessment and investigation of his abdominal symptoms
- Mr R was discharged on 11 July 2013. The neuro‑gastroenterologist prescribed prucalopride to try to help his abdominal symptoms. The discharge letter from UCLH says his Stalevo medication was increased. The OT and physiotherapist had reviewed Mr R and considered he needed an increase in care, which was to include elements of neuro-rehabilitation. It says this had been arranged for after Mr R was discharged home.
- Over the following days Mr R developed severe hallucinations and became very distressed. He was admitted to Conquest Hospital as an emergency on 1 August 2013.
- On 20 August 2013 Mr R was transferred to the Irvine Unit, a rehabilitation centre which is part of the Trust. He was discharged from hospital on 25 September 2013.
- On 29 September 2013 Mr R was taken to Conquest hospital again, having been found distressed and having barricaded himself behind his furniture. The Trust transferred Mr R to a psychiatric ward in the St Anne’s Centre, which is part of the Mental Health Trust.
- The psychiatrist at the Mental Health Trust could not alter Parkinson’s Disease medication. The psychiatrist contacted Mr R’s neurologist at Conquest Hospital. The neurologist saw Mr R on 6 November. Mr Q says the neurologist found Mr R to be under-medicated for his Parkinson’s Disease and changes were discussed.
- The Council updated Mr R’s support plan on 21 November 2013 to say that he wanted to go home with care. He would be self-funding as his savings were over the threshold. Mr R’s support needs included medication management, personal care, continence management and meal preparation.
- The Mental Health Trust discharged Mr R home on 28 November.
- In January 2014 Mr Q says the Council told him a previous application for CHC funding for Mr R had been shredded. The Council arranged for a new checklist to be completed. This met the criteria for a full CHC assessment (DST).
- The Council updated Mr R’s support plan on 4 February 2014. Mr R said his savings had dropped below the threshold and he was therefore eligible for Council funding for his care. He received funding for 32 hours of support per week, of which 29 were ‘core hours’ and the remaining three were to be used at times when his needs were greater.
- On 23 April 2014 the CCG completed a DST. This found Mr Q did not meet the criteria for CHC funding.
- On 23 May 2014 Mr R’s carer emailed the Practice following a visit with a Parkinson’s Specialist Nurse. The Carer asked the Practice to arrange INR and blood sugar tests due to Mr R’s previous history of DVT. This was done the following week and no further action was required.
- The Practice visited Mr R at home regularly, often related to non‑compliance with his medication. In August 2014 Mr R had problems with shortness of breath. His GP diagnosed Mr R with a chest infection and prescribed antibiotics.
- On 13 August the out of hours service visited Mr R because he was short of breath. The out of hours practitioner assessed Mr R and advised a doctor or paramedic practitioner visit to review him. Mr R refused this and admission to hospital.
- On 14 and 15 August paramedics attended Mr R as he was complaining of a shortness of breath. A GP from the Practice also visited Mr R on these days. Mr R continued to refuse hospital admission. Mr R died later on 15 August 2014 of a pulmonary thromboembolism and hypertensive heart disease.
The Council – social care services
- Mr Q complains the Council provided ‘unwanted social care services’ instead of agreed NHS healthcare services following Mr R’s hospital discharge on 11 July 2013. He says this meant Mr R did not receive the healthcare he needed and resulted in a significant deterioration in his health.
- Mr R was due to have a period of reablement from the JCR on discharge from hospital in July 2013. However, the JCR did not have capacity to start straight away. The Council visited Mr R at home on 12 July and offered Mr R a home care service to deliver his care plan. It explained he would need a financial assessment as he may be over the threshold for free social care. Mr R refused this.
- The Council offered to provide Mr R with support, which could have included help with medication and activities of daily living to bridge the gap until the JCR had capacity to provide reablement. However, Mr R declined this support when it was explained he would need a financial assessment. Mr R had capacity to make this decision and this was Mr R’s choice. I have not found the Council provided unwanted social care services and therefore I have not found fault by the Council in this regard.
The Council – communication with the Practice
- Mr Q complains the Council failed to liaise with the Practice in relation to Mr R’s admission to, and discharge from, hospital in 2013.
- There was no requirement for the Council to liaise with the Practice about hospital admissions or discharges. Hospitals send discharge summaries to GPs which outline the reasons for hospital admissions. They also set out information about medication or ongoing health needs. The records show hospital discharge notices were sent to the Practice following Mr R’s hospital admissions.
- The Council should discuss any concerns about healthcare with the Practice if and when they arise. The records show carers contacted the Practice on 25 July 2013 with concerns about Mr R and asked for a medication review. The GP visited the following day. It also contacted the Practice on 2, 17 and 27 December with concerns about Mr R not taking his medication properly. The Practice arranged visits and reviews following these contacts.
- The Practice was responsible for managing Mr R’s medication while he was at home, but the Council and the community nursing team helped by reporting any concerns. I have not seen any evidence to suggest to Council did not contact the Practice when it should have. I have therefore not found fault by the Council about this.
The Council – discharge from the Mental Health Trust in November 2013
- Mr Q complains the Council deliberately intervened to prevent Mr R’s transfer to a care home during discharge planning from the Mental Health Trust in November 2013. He says the Council arranged for a new social care agency that Mr R had to pay an excessive amount for. Mr Q says the agency was not approved by the Council at the time and it did not meet Mr R’s needs. Mr Q says the symptoms that led to Mr R’s death were therefore not identified.
- The records show the Council assessed Mr R’s before his hospital discharge in November 2013. This took into account Mr R’s wishes to return to his own home with support. He was assessed as needing five visits per day by two carers. Records show the Council discussed a financial assessment with Mr R, but he confirmed he had savings that took him above the threshold for funded care. It is recorded that Mr R understood this meant he would have to fund his care until his saving fell below the threshold.
- The records show Mr Q raised concerns about Mr R’s ability to manage at home and the possibility of a care home placement was discussed. The Council discussed this with Mr R, but he was clear he wanted to return to his own home, with the support agreed. The Council offered to arrange the care package or leave it to Mr R and his family. The Council discussed this with Mr Q on 22 November. Mr Q said the agency he had spoken to could not provide the amount of calls needed and he asked the Council if it could find another agency that could provide the care needed.
- The Council identified a new agency that had capacity to take on the number of called needed for Mr R’s care package. It told Mr Q about this on 26 November and sent him the costs. Mr Q also agreed to help Mr R with the process of a financial assessment.
- The records show the agency met with Mr R on 27 November and they agreed the service that would be provided.
- I have seen no evidence the Council prevented Mr R being transferred to a care home or withheld any relevant information about the costs for support at home. The Council assessed Mr R’s needs in accordance with relevant guidance and legislation and Mr R agreed with the care plan. Mr R had mental capacity to make these decisions about his care even if these were different to the wishes of other family members. I have therefore not found fault by the Council about the care planning and support offered to identify a care agency.
- With regards to the suitability of the agency, the records show this was a new agency and it was not on the Council’s list of preferred providers at that time. However, this did not mean it was not suitable to meet Mr R’s needs. Mr R was self-funding and the agency had capacity to provide Mr R’s assessed care needs. I note the CQC inspected the agency shortly after this time and found it met all relevant standards.
- The Council’s records show it made enquiries to the agency after the care provision started to check how the care was working. It is important to note the care agency was not providing healthcare. However, there is evidence it did seek help and advice from the Practice and the out of hours GP service when there were health problems or issues with Mr R’s medication compliance. Carers are not medical professionals and would not be expected to identify the specific symptoms that led to Mr R’s death. They should however refer any concerns to medical professionals. Records by the Council and the Practice show carers did report concerns to the GP and ambulance service. Paramedics and a GP had attended Mr R’s home shortly before he died. However, it is evident Mr R declined treatment and/or hospital admissions.
- I have not seen any evidence the care agency was unable to meet Mr R’s assessed needs or that it did not seek medical help when needed.
- It was not the Council’s role to meet Mr R’s healthcare needs. The records show it helped Mr R identify a care agency that could meet his assessed needs and explained the costs before the care plan started. I have found no fault by the Council.
The Trust – medication
- Mr Q complains the Trust failed to provide Mr R with healthcare services agreed following his discharge from the National Hospital (part of a different NHS Trust) in July 2013. He says these were essential to monitor, manage and record results from a clinical trial of Prucalopride medication.
- The Trust said its Neurology Team did not receive a request to follow up Mr R following his discharge from the National Hospital. The Trust said it reviewed Mr R in November 2013.
- The discharge summary from the National Hospital did not ask the Trust to follow‑up Mr R. It notes the National Hospital would arrange a follow‑up appointment in four weeks, with a further outpatients review in four months. The records show Mr R saw a Consultant Neuro-Gastroenterologist at the National Hospital on 11 September 2013. The clinic letter does not note any follow‑up by the Trust but advises the National Hospital would keep Mr R under review. The records show Mr R had a further appointment at the National Hospital on 11 November, but he was unable to attend this.
- I have seen no evidence the Trust should have followed up or monitored Mr R after his discharge from the National Hospital. However, there is evidence in the records that the Trust contacted Mr R’s consultant at the National Hospital in September 2013 for advice during his hospital admission. I therefore find no fault by the Trust.
- Mr Q complains the Trust discharged Mr R prematurely on 25 September 2013. He says the Trust failed to consider Mr Q’s ability to manage at home safely and self‑medicate. Mr Q also says the Trust failed to provide Mr R with enough community nursing support following his discharge.
- The records show the Trust altered Mr R’s medication during his admission until his psychotic symptoms resolved and his Parkinson’s symptoms were under control. The Trust assessed Mr R on 20 and 24 September 2013 and he was found to be well with no evidence of psychotic symptoms.
- The records from 24 September 2013 show Mr R was happy with the discharge plan. It is noted a social worker had arranged support at home (three visits a day) to include prompting Mr R with medication and monitoring this. A referral was sent to the district nurse. The Trust also noted Mr R’s family would be staying (possibly in the flat above) for a few days.
- The records show an occupational therapist had visited Mr R’s home and all equipment was in place for Mr R’s return home. The Trust also sent a referral to the Community Matron and Mr R’s GP on 25 September for follow up at home. The notes show this was discussed with Mr R and Mr Q on the day of discharge.
- There is evidence of multidisciplinary input into Mr R’s care and planning. Mr R wanted to return home and there was no clinical reason for him to remain in hospital. From the Trust’s perspective, all relevant parties knew of Mr R’s discharge and it appeared follow‑up care was in place.
- The control of Mr R’s symptoms relied on his compliance with his medication. At the point of discharge there was no sign Mr R did not intend to take his medication. The records also noted the pharmacist was putting in place a system to help aid Mr R’s compliance with his medication. There was no indication the Trust staff could have predicted Mr R’s compliance with his medication would have deteriorated so quickly following discharge. I therefore find no fault by the Trust about this hospital discharge.
- Mr Q complains the Trust transferred Mr R to a mental health unit that could not meet his physical health needs shortly after his readmission to hospital in 28 September 2013.
- The records show Mr R presented with increased paranoia because it appeared he was not taking his medication as he believed this was being tampered with. Mr R had locked himself inside his flat. As this was an acute mental health presentation, the Trust referred Mr R to the Mental Health Liaison Team (part of the Mental Health Trust), who assessed him the same day.
- Transfer to a mental health bed will only occur if a patient’s physical health problems are felt manageable on a psychiatric ward and their mental health needs warrant care within a mental health ward.
- The records on 1 October show Mr R was “physically fit for discharge”. This is in the context of acute healthcare needs. It is also recorded Mr R’s family felt it was not safe for Mr R to return home.
- Given Mr R had no acute physical healthcare needs that needed addressing, the options available to the Trust were to discharge Mr R home or transfer him to the care of a mental health unit. There was universal agreement that discharge home was not realistic. Transfer to the Mental Health Trust was therefore unavoidable.
- Additionally, the records show a mental capacity assessment was completed which found Mr R had mental capacity to make decisions about his hospital admission and treatment. Mr R was transferred to the Mental Health Trust as a voluntary patient and there is no record that he objected to this. There was no fault by the Trust in transferring Mr R to the Mental Health Trust on this occasion.
The Trust – community nursing support
- Mr Q complains the Trust failed to provide adequate community nursing support for Mr R following his hospital discharge in November 2013. Mr Q says this meant the Trust failed to identify the symptoms that led to Mr R’s death.
- The Trust said a referral was made to the JCR service prior to Mr R’s hospital discharge on 28 November 2013. This was declined because Mr R did not have rehabilitation potential at that time. As Mr R transferred to the Mental Health Trust after his admission, discharge arrangements were not the Trust’s responsibility. However, records show the Mental Health Trust and the Council arranged assessments of Mr R’s needs and put in place a package of care. I have addressed the Council’s actions above. The records show the Mental Health Trust sent instructions to Mr R’s GP Practice, who made a referral to the Community Nursing Service to give Clexane injections (an anticoagulant).
- The GP records on 29 November 2013 show the district nurse spoke to a GP to advise that Mr R was refusing his Clexane injection. There is therefore evidence that community nursing support was in place, but this was refused. The GP took over Mr R’s care.
- There is no fault by the Trust in respect of arranging community nursing support. Additionally, it is evident the Mental Health Trust made appropriate referrals and arrangements were put in place, but Mr R chose to decline this support and his medication.
The Trust – complaint handling
- Mr Q complains the Trust refused to address his complaint despite assuring him it would do so. He says the Trust then went on to blame him for not complaining sooner, adding to his distress.
- Mr Q complained to the Trust on 22 June 2015. The Trust acknowledged the complaint on 30 June and noted that Mr Q intended to send further information about his complaints. Mr Q sent a further letter on 29 July with more details about the issues he was complaining about.
- The Trust responded on 20 November. It noted Mr Q’s complaints related to events that happened 12-24 months previous. The Trust explained the time limit under the complaint regulations and advised it would not be investigating Mr Q’s complaint because it would not be effective or fair given the time that had elapsed. Additionally, the Trust noted Mr Q had not set out any grounds about why the complaint was not made within the timescales in the complaint regulations.
- As noted in the Trust’s response, the complaint regulations do set out time limits for making complaints and it was not fault to consider the timeliness of Mr Q’s complaint. However, I have not seen any evidence the Trust sought any explanation from Mr Q for the reasons he complained late. The first he knew of the time limit was in the Trust’s response letter advising that it would not investigate his complaint. The Trust therefore did not fully consider the reasons for Mr Q’s late submission and whether there were mitigating circumstances that would lead it to investigate. This is fault.
- However, after Mr Q brought his complaint to the Ombudsmen, the Trust agreed to investigate his complaint and it provided him with a comprehensive response addressing his complaint issues. The Trust also apologised for not clarifying the situation about the time limit and for any distress caused. I consider this a proportionate and appropriate response that addresses this issue. There is therefore no unresolved injustice.
- Mr Q complains the Mental Health Trust provided inadequate care for Mr R’s Parkinson’s Disease when he transferred from the Trust in October 2013. He says the mental health unit did not have a neurologist who could provide adequate care for Mr R’s Parkinson’s Disease. Mr Q also complains the Mental Health Trust failed to transfer Mr R back to a medical ward so he could receive appropriate treatment.
- Mr R’s admission to the mental health unit was due to compliance issues with his medication, paranoid delusions and possible associated risks. The alternative to this admission would have been for Mr R to return home. Therefore it would not be accurate to compare neurological input in the mental health unit to that someone may receive on an acute medical ward. However, I have considered the adequacy of the care Mr R received in the mental health unit for his Parkinson’s disease.
- The Mental Health Trust’s records refer to Mr R’s Parkinson’s Disease and the medication he needed for this. A Parkinson’s Disease Specialist Nurse saw him two days after his admission. The specialist nurse did not suggest any changes to Mr R’s Parkinson’s medication or specific follow-up by the neurology service. The records show the Mental Health Trust contacted the neurology service three times to request a review of Mr R (between 17 and 25 October). The Consultant Neurologist visited Mr R on 28 October but made no changes to medication. The Consultant Neurologist saw Mr R again in clinic on 6 November. The Consultant Neurologist amended Mr R’s medication slightly but did not suggest a further review after a specific time or that Mr R needed to be managed in an acute setting. Additionally, the records show a Neurology Nurse visited Mr R on 14 November.
- The records show the neurology service had close involvement in Mr R’s medication regime while he was in hospital. It did not have any specific concerns about Mr R’s Parkinson’s Disease management or the care setting. There was no fault by the Mental Health Trust in its management of Mr R’s neurological symptoms or in not transferring Mr R back to an acute setting for treatment.
The Practice – medication
- Mr Q complains the Practice failed to monitor and manage Mr R’s medication following his discharge from hospital in July 2013. He says the Practice issued an incorrect repeat prescription on 25 July 2013, which did not reflect his new medication regimen. Mr Q says the Practice did not consider the possible side effects of prucalopride medication, which include risk of hallucinations.
- UCLH discharged Mr R from hospital on 11 July 2013. The records show UCLH only typed the discharge summary letter to the Practice on 31 July and the Practice received it on 9 August. However, the Community Re-Enablement Team contacted the Practice on 25 July to advise of Mr R’s hospital discharge.
- The Practice issued a repeat prescription on 25 July. This did not reflect Mr R’s new medication regimen. This is because the Practice issued this before it had seen a copy of the discharge summary.
- The Practice told the Ombudsmen it used a copy of the discharge summary Mr R was given by the hospital to go through each of Mr R’s medications and discuss these with him. This was during a home visit on 26 July. It said it had planned to review Mr R’s medication again at the next visit, but a fire on 28 July rendered the surgery unusable. Mr R was therefore not followed-up before his readmission to hospital on 1 August.
- The Practice said there were no signs Mr R was in crisis mentally or physically. It said there was no indication Mr R was experiencing thought disorder or hallucinations. There was therefore no indication for the Practice to consider the specific side effects of prucalopride.
- GMC Good Medical Practice says doctors must only prescribe drugs or treatment (including repeat prescriptions) when they have adequate knowledge of the patient’s health. Following a hospital admission a GP needs to reconcile a patient’s medication. This is to make sure the Practice continues to prescribe what a patient is discharged on, provided it is appropriate to continue the medication.
- The records show the Practice was made aware of Mr R’s hospital admission and discharge on 25 July. A GP from the Practice visited Mr R the following day (a Friday). The records show Mr R told the GP he had stopped taking several drugs since his hospital discharge. The records also show the GP discussed Mr R’s medication using the discharge summary the hospital had given to Mr R. The GP noted the medication Mr R had stopped taking on the discharge summary the hospital had given to Mr R. There is therefore evidence the Practice completed a review of Mr R’s medication.
- There were no signs Mr R was acutely unwell (mentally or physically) on 26 July. There was therefore no indication for the GP to consider the specific side effects of prucalopride.
- I note the Practice did not make any changes to medication at the appointment on 26 July. This is however not entirely unsurprising as the records show Mr R declined further intervention or support.
- Although the Practice reviewed Mr R’s medication and discussed medication Mr R had stopped taking, the records do not show the Practice had planned a further review of Mr R’s medication. I am mindful the Practice had a major fire that weekend and the normal operation of the Practice was severely affected. However, the Practice say the record indicates a review was planned. Given there is no clear reference to this in the records and there was no follow-up, there was fault.
- In considering the effect of the fault, I note the records show Mr R declined further intervention or support. This was his choice. There is no evidence Mr R came to harm or that his subsequent readmission to hospital was caused by any faults by the Practice. There was therefore no injustice to Mr R caused by the fault. This has however caused uncertainty and distress to Mr R’s family.
- Mr Q complains the Practice failed to identify Mr R as an ‘adult at risk’. He says if it had, Mr R might not have later suffered being placed in mental health unit for 58 days.
- I have seen no evidence the Council or the Police told the Practice that Mr R was a vulnerable adult. The Practice said it considered Mr R to be vulnerable and the records show it formally noted this on 7 July 2014 as he was housebound.
- Although Mr R was not recorded as an ‘adult at risk’ before his admission to a mental health unit, there is no evidence this affected the care the Practice provided.
- There is no requirement for GP Practices to record a patient as ‘at risk’ in the records. Recording Mr R’s status as a vulnerable adult before July 2014 would not have changed the care the Practice provided. There is therefore no fault by the Practice in not recording Mr R as an ‘adult at risk’ before his hospital admission.
- Mr Q complains the Practice failed to liaise with other agencies involved in Mr R’s care about his Stalevo medication. In particular Mr Q says it failed to seek advice from UHCL or the manufacturers of Stalevo to discuss whether slow gastric motility might affect absorption.
- Mr R was under the care of UCLH and the Trust between 2011 and 2013 for the management of his Parkinson’s Disease. His consultants therefore managed and monitored his medication. The Practice prescribed medication, but it is not a GP’s role to initiate complex treatment for advanced Parkinson’s Disease. However, the records show when concerns were raised about Mr R’s medication, the Practice contacted either the Trust’s neurology department or UCLH. While it was the specialist’s role to review and amend treatment plans, the evidence shows the Practice took appropriate action to refer Mr R to his specialist and seek advice about possible problems with his Parkinson’s medication, including Stalevo. I therefore find no fault by the Practice.
The Practice – kidney stones
- Mr Q says Mr R was diagnosed with kidney stones by a urologist at the Trust. He says these could not be treated with a surgical procedure because Mr R was ‘at serious risk of DVT’. Mr Q complains the Practice failed to treat Mr R’s kidney stones or take more notice of the notification that Mr R was at risk of DVT.
- The Trust proposed shock wave lithotripsy (treatment using ultrasound shock waves to break a kidney stone into smaller pieces) in December 2013. The Practice wrote to the urologist to point out Mr R was on Clexane injections (an anticoagulant) because of a recent DVT. The Trust confirmed this made shock wave lithotripsy high risk and said it would therefore arrange an outpatient appointment for Mr R to discuss other options.
- The treatment of Mr R’s kidney stones was undertaken entirely in secondary care and the Practice did not have a role in this. I therefore find no fault by the Practice in this regard.
- Mr Q complains the Practice failed to examine Mr R when social care staff reported that he may be suffering from DVT. Mr Q says the failure to identify DVT meant the Practice took no action to prevent Mr R’s thromboembolism.
- On 22 May 2014 a Parkinson’s Disease specialist nurse, an occupational therapist, a social worker and a care manager reviewed Mr R at his home. The following day the care manager emailed the Practice to advise it about the meeting. The care manager said that as Mr R has had problems with DVTs, the Parkinson’s nurse specialist ‘suggested that [Mr R] should have his INR checked…’ No further information was given in the email and there was no suggestion Mr R was suffering from a DVT. The Parkinson’s Disease specialist nurse also sent a letter to the Practice the same day. There was no mention of DVT or Mr R having any clinical problem with his legs in this letter.
- The records show the Practice requested a D-dimer test on 28 May 2014. A community phlebotomist took blood on 30 May. The Practice received the blood test results on 2 June. It recorded M R’s D-dimer levels were slightly raised. The records show the Practice contacted Mr R to check if he had any symptoms that would suggest DVT. He denied any pains in his calf.
- The GP considered the abnormal D-dimer result, in conjunction with other test results (Prothrombin Time – a measure for blood clotting), was not significant. The GP said under the DVT protocol, the Two Level DVT Wells Score was less than 1, which meant ‘unlikely DVT’. At the time, Mr R was also awaiting investigations to rule out a gastro‑intestinal bleed as a possible cause for his anaemia. The Practice considered starting anticoagulants but felt the risk of bleeding was higher than DVT. The records show a nurse practitioner visited Mr R on 5 June and recorded there was no clinical sign of DVT.
- There was no clinical indication for an INR or D-Dimer test. However, the records show the Practice arranged the D-Dimer test and followed up with an examination. There was no clinical sign of a DVT or pulmonary embolus and therefore no indication to investigate for either. There is therefore no fault by the Practice in relation to its examination of Mr R for a possible DVT or thromboembolism.
The Practice – consultation on 14 August 2014
- Mr Q complains the Practice failed to take into account Mr R’s medical history or recognise how seriously ill he was when a GP saw him a day before he died. He says the GP should have noted Mr R’s medical history, including the history of DVT and the results from an ECG reported by the out of hours service the previous day. Mr Q says Mr R’s refusal to go to hospital should not have prevented the GP diagnosing DVT.
- The records show Mr R requested a home visit because he was feeling wheezy and had stomach pains. The GP visited Mr R and recorded he was “chesty” and had a cough for three days. The GP noted Mr R was having difficulty using an inhaler (used to help open the airways) and was feeling tired. The GP recorded Mr R was speaking in sentences and had a respiratory rate within “normal” levels. The GP could also hear crackles when listening to Mr R’s lungs. The GP prescribed antibiotics for a chest infection and changed Mr R’s inhaler to a different type.
- The records show the out of hours service visited Mr R on 13 August and sent details of the consultation later that night. However, this was not added to the GP records until after the GP visited Mr Q on 14 August. The ECG information was therefore not available to the GP.
- As Mr R was coughing and had crackles in his chest, the GP should have worked out Mr R’s CRB-65 score as the working diagnosis was community-acquired pneumonia. If Mr R’s blood pressure or oxygen saturations had been low a hospital admission may have been suggested. The lack of investigations in line with guidance means it is not possible to say whether hospital admission for community‑acquired pneumonia was indicated. This is fault.
- However, treatment with antibiotics was in line with NICE guidelines based on the GP’s documented clinical findings. It is not clear why the out of hours summary with the ECG finding was not available to the GP, but the findings are non‑specific. They would not have changed the GP’s management or treatment of Mr R. There is no fault in the clinical treatment of Mr R.
- In considering the injustice from the Practice’s fault of not recording a CRB‑65 score, it is not possible to say what the findings would have been or if hospital admission would have been indicated. There is therefore a possible missed opportunity for Mr R to have been advised to attend hospital for investigations and treatment. However, it is clear from the records that Mr R did not wish to go into hospital. In the days before he died Mr R had refused admission to hospital consistently against the medical professionals’ advice. It was Mr R’s choice to decline hospital admission. However, I have based my findings on the history and information I have seen. On the balance of probabilities, it seems unlikely Mr R would have agreed to go to hospital even if his blood pressure or oxygen saturation levels indicated hospital admission was advisable. I cannot therefore link Mr R’s subsequent deterioration to the faults identified by the Practice or say the outcome would have been different for Mr R. However, the uncertainty from the faults has clearly caused distress for Mr R’s family.
- The Practice has agreed the following actions to address the injustice caused by the faults identified in this complaint:
- to apologise to Mr Q for the distress due to the uncertainty caused by the faults identified with the lack of a CRB-65 score recorded;
- review this case and formulate an action plan to address the faults identified in this complaint.
- I found no fault by the Council in relation to it providing unwanted social services for Mr R or in its communication with his GP practice.
- I did not find fault by the Council in its arrangement of social care services following Mr R’s discharge from hospital in November 2013.
- I found no fault by the Trust in relation to its follow-up of Mr R and monitoring of medication after he was discharged the National Hospital.
- I did not find fault in the Trust’s actions in arranging Mr R’s hospital discharge in September 2013 or with its decision to transfer Mr R to the Mental Health Trust in October 2013.
- I did not find fault by the Trust in relation to arranging community nursing support after Mr R’s hospital discharge in November 2013.
- I have found there was fault by the Trust in its complaint handling. However, this has already been addressed by the Trust and it has apologised to Mr Q.
- I found no fault by the Mental Health Trust with its management of Mr R’s Parkinson’s Disease during his hospital admission from October 2013.
- I found no fault by the Practice in monitoring side effects of prucalopride medication.
- I found no fault by the Practice in reviewing Mr R’s medication after he was discharged from hospital, but there was fault in not adequately recording details of further medication reviews/planning. However, I do not consider this caused Mr R an injustice.
- I did not find fault by the Practice in its recording of Mr R as a vulnerable adult or with its communication with other agencies.
- I found the Practice was not at fault in its treatment of Mr R’s kidney stones nor with its investigations into a DVT when a care manager asked for tests to be done.
- I found there was fault by the Practice in relation to assessing Mr R when he was suspected of having community acquired pneumonia. This resulted in a possible post opportunity for the Practice to suggest Mr R be admitted to hospital. However, given Mr R’s persistent refusal to go to hospital in the preceding days, on the balance of probabilities, I consider it unlikely Mr R would have taken the advice. There was no fault in the Practice’s clinical management of Mr R’s community acquired pneumonia.
- The uncertainty caused by the faults identified have clearly caused Mr R’s family distress. The Practice has agreed actions to address the injustice caused by the faults and review this case with a view to making service improvements. I therefore intend to complete my investigation.
Parts of the complaint that I did not investigate
- Mr Q complains the CCG failed to accurately assess Mr R’s needs in April 2014 resulting in him not receiving Continuing Healthcare (CHC) funding.
- The CCG completed a DST on 23 April 2014. It wrote to Mr R on 6 June to inform him of the decision not to award CHC funding. The letter included information about how to appeal the decision if he was unhappy. The CCG also sent a copy of the letter to Mr Q.
- Mr Q complained to the CCG on 25 June 2014. The CCG’s response on 27 August explained the CHC process including how to appeal. This was reiterated in the CCG’s final response letter dated 5 November.
- The National Framework for NHS Continuing Healthcare sets out a clear process for appealing decisions about CHC. This includes IRPs and, at the very end of the process, complaints to the Health Service Ombudsman.
- The Health Service Ombudsman cannot make or remake decisions about a person’s eligibility for CHC. In complaints about CHC the Health Service Ombudsman looks at the way IRPs handled cases.
- In this case Mr Q has not yet exhausted the local appeals process. As such, it would be premature for the Ombudsmen to consider Mr Q’s complaints about the CHC assessment process. The CCG told Mr Q of the local appeals process in June 2014, including information that appeals should be made within six months of the decision. Mr Q did not request an appeal within this timescale. The CCG confirmed to the Ombudsmen that unless Mr Q provide evidence of exceptional circumstances for not following the appeals process sooner, it would not accept a request for an appeal.
- In these circumstances I have not investigated this issue as there is no realistic prospect of finding it was the fault of the CCG that Mr Q did not complete the proper appeals process. It remains open to Mr Q to request an appeal should he consider there are exceptional circumstances for it to allow this outside of the normal time frame.
Investigator's decision on behalf of the Ombudsman