General Practice

Lostwithiel Medical Practice (17 007 723)

Statement Not upheld General Practice 19-Feb-2019

Summary: I consider Cornwall Council (the Council) was at fault when it sent contradictory information to Mr X saying it would not issue an education, health and care (EHC) plan for Miss Y, and then saying it would issue one. Due to Miss Y's age, Mr X has lost the opportunity to appeal the Council's decision. Cornwall Partnership NHS Foundation Trust (the Trust) delayed carrying out blood tests and an ECG. This caused uncertainty to Mr X. Also, the Trust used the wrong sized feeding tube for Miss Y. This caused pain to Miss Y and distress to Mr X. Smile Together Dental CIC (the Dental Service) did not provide Miss Y with an appointment since September 2016. This caused frustration to Mr X. Also, the Council and Kernow Clinical Commissioning Group (the CCG) delayed providing responses to Mr X's complaints, and did not keep him updated during the complaint handling process. This compounded the distress he had already suffered. The Ombudsmen made recommendations to remedy the injustices.

Dr C E Atkin (17 014 697)

Statement Not upheld General Practice 07-Feb-2019

Summary: The Ombudsmen do not consider Dr C E Atkin (the GP) missed an opportunity to refer Mr B to hospital with suspected pneumonia. Alpine Lodge Nursing Home (the Home) did not provide Mr B with appropriate fluids between January and June 2017. It also did not complete a robust assessment of his hydration needs on admission in October 2016. This caused Mr B to suffer chronic dehydration, and the family suffered distress at witnessing that.

Mill View Surgery (17 017 844)

Statement Not upheld General Practice 15-Jan-2019

Summary: Mrs T complained about problems she had accessing funding for her daughter, Miss R. The Council did not complete reviews properly and failed to allocate a social worker to Miss R's case. The CCG took over 12 months to decide that Miss R was eligible for healthcare funding and took too long to agree a suitable support plan. This caused injustice to Miss R's paid carers which include Mrs T. The Council and the CCG agreed to the Ombudsmen's recommendations to apologise, pay a financial remedy, complete a retrospective review of Miss R's entitlement to healthcare funding and consider whether any lessons can be learnt.

Stapenhill Medical Centre (17 017 844)

Statement Not upheld General Practice 15-Jan-2019

Summary: Mrs T complained about problems she had accessing funding for her daughter, Miss R. The Council did not complete reviews properly and failed to allocate a social worker to Miss R's case. The CCG took over 12 months to decide that Miss R was eligible for healthcare funding and took too long to agree a suitable support plan. This caused injustice to Miss R's paid carers which include Mrs T. The Council and the CCG agreed to the Ombudsmen's recommendations to apologise, pay a financial remedy, complete a retrospective review of Miss R's entitlement to healthcare funding and consider whether any lessons can be learnt.

Mendip Vale Medical Practice (16 016 635)

Statement Not upheld General Practice 20-Dec-2018

Summary: The nursing Home failed to adequately monitor a resident (Mrs F)'s nutrition and respond to her significant weight loss. The Home also failed to make sure Mrs F was reviewed by a GP within a reasonable timeframe, failed to keep complete and accurate patient records, and failed to keep Mrs F's daughter informed about her wellbeing. These faults caused distress to Mrs F and her daughter Ms B. The Home has already taken action to address the faults including staff training and supervision, and monitoring and auditing of care plans and records. The Home has also agreed to apologise to Ms B, and to monitor actions taken in response to significant weight loss to ensure staff have appropriate knowledge and skills. The Home has agreed to pay financial redress. We did not identify fault by the GP Practice.

Warrior Square Surgery (16 015 553)

Statement Upheld General Practice 30-Nov-2018

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.

St. Hilary Group Practice (16 003 437)

Statement Not upheld General Practice 18-Sep-2018

Summary: A woman complained about the care provided to her late sister, who had learning disabilities. She said a hospital, psychiatric ward and GP practice did not identify that her sister had pancreatic cancer until it was too late to treat, and the GP took too long to arrange palliative care. Further, that the council placed restrictions on her contact with her sister because of safeguarding concerns. She said her sister's death was potentially avoidable and she suffered unnecessarily. The Ombudsmen found that there were some delayed investigations but that the death was not avoidable. The hospital has agreed to address this. The Ombudsmen did not investigate the safeguarding concerns.

Great Western Hospitals NHS Foundation Trust (16 013 254)

Statement Upheld General Practice 21-Aug-2018

Summary: Mrs B complains about the standard of care her father, Mr T, received in a care home arranged and funded by the Council. He was found unwell on the floor with bruising to his arm but care staff did not identify a possible stroke and call an ambulance. The Ombudsmen find staff acted appropriately by contacting the out of hours GP service and acting on the advice given. Mrs B also complains that the out of hours doctor failed to identify a possible stroke during a telephone conversation with care home staff and that the GP delayed in visiting Mr T. The Ombudsmen find the doctor was at fault in failing to return the care home's call within 20 minutes but was not at fault in failing to identify a possible stroke. He acted appropriately by logging the case for a routine visit within six hours.

Oakenhall Medical Practice (17 006 806)

Statement Not upheld General Practice 09-Aug-2018

Summary: Mr P complained about the care provided to his mother Mrs D by a council, an NHS Trust and a GP Practice. The Ombudsmen investigated his concerns that the council did not arrange medical care when Mrs D had delirium caused by an infection, that the GP failed to diagnose and treat her, that the hospital did not manage her risk of falls properly so she broke her hip, and that the council inappropriately wanted to move her to an extra care scheme rather than to residential care with her husband. We found that medical care was arranged and the GP acted appropriately. The hospital did not properly assess Mrs D's risk of falls, but we cannot say this caused the fall. The council did not properly decide that Mrs D should move to an extra care scheme, which caused some distress. The council has agreed to apologise and make improvements.

The Baldock Surgery (17 010 928)

Statement Upheld General Practice 30-Jul-2018

Summary: The Ombudsmen find fault in an independent investigation the Council commissioned. It was not properly multi disciplinary and failed to provide a comprehensive response. The Council has agreed to commission a new investigation, to properly include and consider all the relevant health organisations.