The Orchard Surgery (21 005 391)
Statement Not upheld General Practice 17-Mar-2022
Summary: We consider Boots UK Limited contributed to delays getting end of life medication to Mrs C before she died. Mr B suffered avoidable distress witnessing his mother in pain before she died. Boots should pay Mr B financial redress to recognise his injustice.
Worthing Medical Group (21 000 200)
Statement Upheld General Practice 01-Mar-2022
Summary: We found fault by a care home acting on behalf of the Council regarding the care it provided to Mr X, an elderly man with complex care needs. We found the care home failed to support Mr X and his wife, Mrs X, to make an informed choice about his GP registration. We also found the care home failed to administer palliative medication to Mr X as prescribed. In addition, we found fault by the Practice as it failed to discuss Mr X's end of life management plan with Mrs X. These failings caused Mrs X distress. The Council and Practice will apologise for this fault and take action to prevent similar problems occurring in future.
North Swindon Practice Home Ground Surgery (20 011 171)
Statement Upheld General Practice 18-Aug-2021
Summary: Mrs B complained about information an NHS Trust provided to the Council's commissioned care home provider when her late father was discharged from hospital in December 2019. She complains a Surgery prescribed antibiotics but failed to send the prescription to the pharmacy. She also said the Home delayed in following up on the medication her father needed, and this contributed to his untimely death. We found the Trust at fault for poor record keeping when it dealt with the discharge, but it improved. Faults in the way the Surgery made an electronic request for medication and the Home's failure to take follow up action caused delay in the medication being received. The Surgery and the Home also missed an opportunity to report the incident to the Council so it could consider its safeguarding procedures. The authorities have agreed to our recommendations and the Council will monitor the Home to ensure it improves the way it records discharge information and it will provide safeguarding training if necessary. The Surgery will remind its staff of the importance of reporting safeguarding concerns to the Council when dealing with incidents relating to patient safety. The Home and the Surgery will apologise to Mrs B for the missed opportunity which contributed to doubt she has about the events which occurred.
Liscard Group Practice (20 011 447)
Statement Not upheld General Practice 18-Aug-2021
Summary: Wirral University Teaching Hospital NHS Foundation Trust acted with fault by not including Mrs X's medication changes to her discharge paperwork. The Trust has remedied the injustice to Mrs X's son, Dr Y. Also, Liscard Group Practice and Leighton Court Care Home did not contribute to a delay restarting Mrs X's medication.
Tilehurst Village Surgery (20 006 862)
Statement Not upheld General Practice 10-Aug-2021
Summary: West Berkshire County Council carried out a safeguarding investigation into Mrs Y's weight loss in line with the local procedures. However, a GP at Tilehurst Village Surgery did not monitor Mrs Y's weight despite agreeing to. That fault caused Mrs Y's daughter, Mrs X, uncertainty. The GP recognised that fault and has appropriately remedied the injustice to Mrs X and potentially others.
Old School Surgery (20 001 063)
Statement Not upheld General Practice 29-Mar-2021
Summary: We consider East Sussex County Council, Change Grow Live, Sussex Partnership NHS Foundation Trust and Old School Surgery missed the opportunity to meet and discuss Ms E's worsening alcohol misuse and mental health before she died. That has caused Ms E's family uncertainty. They will not know if a joint meeting would have changed the outcome. The organisations should apologise for that fault.
Abbey Medical Centre (19 018 460)
Statement Not upheld General Practice 23-Mar-2021
Summary: Dr A has complained in relation to the care of her mother at a Care Home and the delay in a fast-track application for Continuing Healthcare funding. We do not find fault with the care provided or the delay in the application that caused Dr A the injustice has claimed.
Local Care Direct (18 013 815)
Statement Upheld General Practice 10-Sep-2020
Summary: Mrs X complains about the care her brother, Mr Z, received at the end of his life. The Ombudsmen have found faults in the care provided by Mr Z's care home and an out of hours GP service. We have found no fault in the actions of Mr Z's GP practice. The care home and out of hours GP service accept our recommendations. We have therefore completed our investigation.
Grange Park Surgery (18 013 815)
Statement Not upheld General Practice 10-Sep-2020
Summary: Mrs X complains about the care her brother, Mr Z, received at the end of his life. The Ombudsmen have found faults in the care provided by Mr Z's care home and an out of hours GP service. We have found no fault in the actions of Mr Z's GP practice. The care home and out of hours GP service accept our recommendations. We have therefore completed our investigation.
Knightsbridge Medical Centre (18 006 669)
Statement Upheld General Practice 24-Aug-2020
Summary: Mrs V complains about the care of her late husband by a care home and a GP Practice in the last months of his life. We have upheld some of Mrs V's complaints about the Home's care of Mr V and its complaint handling. We have also upheld some of Mrs V's complaints about the GP Practice's handling of end of life medication and complaint handling. Bupa, the Council and the GP Practice accept our recommendations. We have therefore completed our investigation.