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Mayfield Medical Centre (17 009 920a)

Category : Health > General Practice

Decision : Not upheld

Decision date : 24 Jan 2018

The Ombudsman's final decision:

Summary: The Ombudsmen find there were failings in the care the Council, a GP Practice and a Pharmacy provided to Mrs E. The Council and Practice have already accepted and addressed the failings they were responsible for. The Ombudsmen recommend the Pharmacy takes steps to put right the injustice its failings caused.

The complaint

  1. Mr M complains about the care and support Torbay Council (the Council), Mayfield Medical Centre (the Practice) and Day Lewis Pharmacy (the Pharmacy) gave his mother, Mrs E, in November and December 2016.
  2. Mr M complains about:
  • A double dose of morphine. Mr M complains that carers gave his mother a double dose of morphine in November 2016. Mr M complains staff failed to properly report the incident.
  • A delay in arranging a GP visit. Mr M complains about a delay in the Practice arranging a home visit to see his mother in December 2016. Mr M said he told the Practice Mrs E was unwell on 5 December 2016 and chased this up on 8 and 9 December 2016, but a doctor did not visit her until 12 December 2016.
  • A failure to provide regular medications. Mr M complains that professionals failed to ensure Mrs E had her regular medication from 2 December 2016 until 9 December 2016. Mr M said Mrs E took a range of tablets and complains the missing doses contributed to the stroke she suffered.
  1. Mr M believes if someone had visited Mrs E in good time, and had the mistakes not been made with her medication, her death could have been avoided.

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The Ombudsmen’s role and powers

  1. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
  2. The Ombudsmen will not generally investigate a complaint unless they are satisfied the matter has been brought to the relevant organisation’s attention and that organisation has had a reasonable opportunity to investigate and reply to the complaint (Local Government Act 1974 section 26(5), as amended and Health Service Commissioners Act 1993, section 9(5)). However, in the case of joint complaints (i.e. those deemed suitable for investigation by the Joint Working Team operated by both PHSO and LGSCO), if one organisation has investigated and replied to the complaint but another organisation has not, the Ombudsmen may decide to exercise their discretion to investigation the complaint against all organisations, so that the issues can be considered in the round.
  3. 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).
  4. 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.
  5. 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).

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How I considered this complaint

  1. I read the correspondence Mr M sent to the Ombudsmen and spoke to him about the complaint over the telephone. I asked for information from the Council, Practice and Pharmacy and considered their responses and records. I also got and read copies of Mrs E’s records of her admission to hospital from 12 December 2016.
  2. I read relevant guidance and policies and got advice from a clinical adviser – a GP with relevant experience.
  3. I shared a confidential copy of my draft decision with Mr M and all the organisations to explain my provisional findings. I invited their comments on this and considered the responses I received.

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What I found

  1. Mrs E lived in her own flat in an Extra Care housing complex. She had type one diabetes, high blood pressure and chronic kidney disease. Mrs E had also had a knee cap replaced in the past and had suffered blood clots in her legs. In addition, Mrs E was incontinent of urine which caused associated problems with her skin which caused her a lot of discomfort. Professionals had found this aspect of Mrs E’s care difficult to manage.
  2. The Council funded a package of care for Mrs E from Care Support, an on-site service. Carers visited Mrs E throughout the day and helped with a range of things, including giving medication.


Double dose of morphine

  1. Doctors had prescribed morphine for Mrs E for pain relief. The prescription allowed between 2.5 and 5ml, to be given in the evening. In the evening of 7 November 2016 two carers visited Mrs E at around 8pm to give her this medication. A carer gave Mrs E 10ml.
  2. Care Support has a medication policy. This states that errors must be reported to a line manager without delay. This happened. A carer called Care Support’s Head of Care to explain what they had done. The carer then called 111 which arranged for paramedics to visit Mrs E. The paramedic crew examined Mrs E and said she seemed fine. They offered reassurance that the excess dose was minor and unlikely to have a significant impact. Other than observing Mrs E, the paramedics did not provide any treatment.
  3. The error (giving Mrs E 10ml rather than 5ml) should not have happened and is fault. However, the records I have seen show that staff took quick action to make sure Mrs E was safe and medical professionals confirmed she was. I have not seen any evidence that this one-off increased dose caused Mrs E any harm.
  4. The records also show Care Support was open about what had happened. The Head of Care completed an Incident Reporting Form and spoke to the member of staff about the incident and stressed the need to check doses carefully. The Head of Care also telephoned the Practice (the day after the incident) and told them what had happened. The Practice already knew as they had received a report from the out of hours service.
  5. Overall, I have not found evidence to show this mistake caused Mrs E an injustice as she did not come to any harm. There is also evidence to show Care Support addressed the mistake quickly. Therefore, I have not recommended any further action.

Delay in arranging a GP visit

Relevant events in the months before December 2016

  1. In September 2016 Mrs E did not have a catheter and wore incontinence pads. However, she continued to have problems with her skin which caused her a lot of discomfort. Mrs E’s regular GP, Dr A, saw her about this issue at the start of October 2016 and referred her to a Consultant Gynaecologist, to rule out cancer.
  2. Mrs E saw the gynaecologist later that month. They noted Mrs E had complex medical needs which had been difficult to manage. The gynaecologist recommended an ointment but said they did not think there was anything else they could do to help.
  3. In early November 2016 Mr M and his partner visited the Practice and said the cream was causing Mrs E pain. In the middle of November 2016 the GP spoke to them both and said there were limits to what they could do about these problems. They suggested trying a catheter again. Around a week later a community nurse said they had tried this but it was very sore for Mrs E and did not help with her long-term pain.

Requests for a GP visit

  1. Mr M said he went to the Practice on 5 December 2016 (a Monday) and asked someone to go and see his mother due to pain ‘down below’. Mr M said he thought this pain was a continuation of a lasting problem. The Practice’s records from 5 December state that Mr M’s partner called into the Practice and wanted a message to be passed to Dr A. The record matches what Mr M said in terms of why they wanted a GP visit. Namely, that Mrs E was still ‘in pain low abdo [the lower abdomen] and down below – very sore’.
  2. The Practice said that, as the message was left for a specific GP and because it related to a long-standing issue, it did not think Mrs E’s family were asking for an urgent visit. It said the message was added to Dr A’s list but she did not have time to follow it up the same day. The Practice said Dr A was on call on Tuesday afternoon and this kept her out of the surgery until late. It said, as a result, Dr A did not work on the messages from the previous day. The Practice said Dr A was not scheduled to work on Wednesday. It said she came into the surgery to complete some administrative tasks but did not consider the message about Mrs E to be urgent and left this for her next working days.
  3. Mr M said he went into the Practice on Thursday and asked again for someone to visit Mrs E. He said the member of staff told him that Dr A was on holiday. Mr M said he told the member of staff he did not mind which GP went to visit, and explained that his mother’s pain was severe. Mr M said he visited the Practice again on the Friday to chase things up. These events are not recorded in the Practice’s records.
  4. The Practice said Dr A called back in the evening on Friday and arranged to visit on Monday morning. Mr M said neither he nor his partner can remember this call. The next entry in the Practice’s records (after 5 December 2016) is on 12 December 2016 (the following Monday). This states that Dr A visited Mrs E in the morning as had been planned in a telephone call with Mr M’s partner on Friday.

Events on 12 December 2016

  1. By the time of Dr A’s visit on 12 December 2016 Mrs E had been admitted to hospital. At around 3am that morning a carer felt Mrs E was very distant, with a stiff right arm and staring at the ceiling. They called an ambulance which took Mrs E to A&E. In A&E doctors diagnosed Mrs E as having suffered a stroke and felt she might be suffering from a chest infection.

National standards for home visits

  1. In 2013 the Department of Health published a Standard General Medical Services Contract. This set out the services GP surgeries should provide. I have used this as a measure of good practice.
  2. Section eight of the contract says that surgeries must provide essential services to its patients during core hours (from 8am until 6.30pm), or arrange for patients to have access to such services. Sections 7.6.1 and 7.6.2 of the contract relate to home visits. There is no automatic right to a home visit. The contract sets out that decisions about whether to make a home visit are matters of clinical judgement.

The Practice’s home visit policy

  1. The Practice has a home visit policy. This says that reception staff should record requests for home visits and pass them to a doctor. The policy says a doctor will then triage the requests over the telephone. They will use their clinical judgement to decide if a home visit is needed and, if so, how urgently. This policy is in line with good practice.


  1. The Practice did not triage the home visit request of 5 December 2016. This is fault as it did not act in line with its home visit policy. The Practice has recognised it failed to contact Mr M about his message, and apologised for the upset this caused him.
  2. In its response to my enquiries the Practice said this was a significant issue. It said it has reflected on what happened at length, and taken steps to improve the way it records messages. The Practice also said it has changed its system for managing home visits.
  3. The Practice said it did not believe the delay in contacting Mr M contributed to her admission to hospital. It said the reasons for the requested home visit were unrelated to the reasons why Mrs E had to go to hospital.
  4. If the Practice had handled the request of 5 December 2016 in line with its policy, it may not have resulted in a home visit the same day. This is because the request related to a long-standing issue, and not a new problem. However, it is possible it would have led to a visit (by either Dr A or another GP) that week. This visit would have been to look into Mrs E’s continued soreness. Therefore, the Practice’s conclusion about the impact of the fault here is reasonable. Mrs E did not go into hospital because of a gynaecological issue. I cannot see it would have been possible for a GP to have pre-empted what happened in the early hours of 12 December 2016 even if they had visited the previous week. Therefore, I have not recommended any further action as the Practice has already addressed what went wrong in this case.

Failure to provide regular medication

Arrangements for ordering and delivering Mrs E’s medication

  1. Mrs E took seven different medications regularly each month:
  • Adcal-D3 – a calcium and vitamin D supplement to help maintain bone health
  • Amitriptyline – for nerve pain and to aid sleep
  • Aspirin – to help prevent blood clots
  • Fesoterodine – to help with bladder problems
  • Omeprazole – for heartburn and indigestion
  • Sertraline – for depression and anxiety
  • Simvastatin – to lower cholesterol
  1. She also regularly took alendronic acid (to help with the use of Adcal-D3), insulin (to help control diabetes), paracetamol (for pain relief) and had butec patches (for pain relief).
  2. The Pharmacy put the seven regular medicines listed above in a monitored dosage system, called a ‘blister pack’. This helped make it clear what she needed to take at different times of the day and week. The Pharmacy delivered Mrs E’s medication to her and she kept it in a cupboard in her kitchen.
  3. Staff from Care Support helped Mrs E to take her medication. Each time they gave Mrs E medication they would record this on a specific record. Staff recorded whether they had given the blister pack as a whole, rather than keeping a record for each medicine inside it.
  4. Mrs E had repeat prescriptions for these medications. Repeat prescriptions do not need to be ordered by the patient. The Practice’s Repeat Prescription and Medication Review Protocol notes that carers, community nurses, pharmacists and care home staff can also order them.
  5. In this case the Pharmacy ordered repeat prescriptions on Mrs E’s behalf. It did this in line with its Standard Operating Procedure 175: Repeat Prescription Service. Level four of this procedure notes the Pharmacy offers a service where it will keep the repeat prescription slip and order medication on behalf of the patient when needed. With this system the Practice prescribes enough medication to last for 28 days. The Pharmacy uses a diary system to make sure it then orders a new supply in time to make sure the patient does not go without.
  6. The Pharmacy also uses its Standard Operating Procedure 149: Monitored Dosage Systems for community patients. This notes that when there are any problems or queries about arrangements for blister packs (when the patient does not have any input) staff need to have telephone or email contact with the relevant GP surgery to resolve them.

Timeline of events

  1. Records from the Pharmacy show it dispensed all seven of the medicines in Mrs E’s blister pack (and some further items) on 6 September 2016.
  2. It next dispensed all seven of the blister pack medications (plus other items) on 5 October 2016. This was 29 days after 6 September.
  3. The Pharmacy next dispensed the blister pack medications (and other items) on 31 October 2016, 26 days later.
  4. I have seen medication records from Care Support from 12 September to 11 December 2016. They show that staff visited Mrs E and gave her the medication from the blister pack four times every day from 12 September to 5 December 2016. Mr M said Mrs E told him on 2 December 2016 that she had run out of medication. However, Care Support’s records include signatures to show staff gave her medication after this time.
  5. On 5 December 2016 a carer wrote in the daily notes that ‘Blister will run out tomorrow lunch time. No more in cupboard’. The medication records show carers gave Mrs E medication from her blister pack on 6 December 2016 at 7.30am and 12.15pm. At 4.15pm that day they noted there was none available.
  6. On 6 December 2016 Care Support recorded that it had placed a full medication order and asked for it urgently. The record does not say who they placed the order with but an email from 7 December 2016 said they had called the Practice. The email said they chased this up and it also noted that Mrs E had ‘been without her meds for two days’.
  7. The Practice records show it received a request for medication in the late morning of 7 December 2016 and issued the prescription at 4.50pm. On 8 December 2016 Care Support recorded that staff called the Pharmacy to chase up Mrs E’s medication. Records from the Pharmacy show it dispensed the medication that day. A team leader from Care Support signed to say they received medication at 3.35pm on 9 December 2016. The Care Support medication records show staff started to give Mrs E medication from her blister pack again at 9.15am on 10 December 2016. They gave it to her three mores time that day, and four times on 11 December 2016.
  8. Based on this information, I find Mrs E’s blister pack medication ran out in the afternoon of 6 December 2016 and she began to receive it again in the morning of 10 December 2016. This meant she was left without her blister pack medication for three and a half days. The medication records show that staff continued to give Mrs E (or prompted her to take) other medication throughout this time, including insulin, morphine and paracetamol.


  1. Mrs E was a vulnerable member of society. She had several health problems and needed help in many aspects of day to day life. This included help to make sure she received and took all her medication on time. Systems were in place to manage this. They did not work on this occasion. If they had Mrs E would not have had to go without medication for three and a half days.
  2. It was the Pharmacy’s responsibility to order medication for Mrs E. A new order should have been placed around 24 November 2016. I have not seen any evidence to show that an order was placed then, and the Pharmacy has accepted that it appears likely it did not happen.
  3. If the Pharmacy had concerns about whether the medication was still needed it could have spoken to the Practice, as its procedure about monitored dosage systems suggests. Therefore, I find the Pharmacy responsible for the fault that occurred here, which meant Mrs E’s supply of medication was interrupted.
  4. There is evidence to show Care Support chased things up when it recognised the problem. There is also evidence to show the Practice issued Mrs E’s prescription on the same day it received the order. Therefore, I have not found fault on their part.

Impact of missing medication

  1. An ambulance took Mrs E to A&E early on 12 December 2016. Doctors found she had suffered a small stroke and thought she might have a chest infection. The hospital tried to treat Mrs E and therapists tried to help her rehabilitate. However, Mrs E had another, larger stroke while she was in hospital. On 16 January 2017 doctors felt Mrs E was coming to the end of her life and focused on keeping her comfortable. The hospital transferred Mrs E to a care home on 20 January 2017 and she sadly died the following day.
  2. Mr M feels the missing doses of medication contributed to the stroke Mrs E had. He feels that Mrs E may still be alive if this had not happened.
  3. Mrs E had several existing health problems which meant she had an increased risk of having a stroke. Most of the regular medication Mrs E took was not prescribed to reduce this risk. They were prescribed to help control other issues, and to ease Mrs E’s pain. Mrs E did take aspirin to help prevent blood clots and she missed doses of this when her medication ran out. However, on the balance of probabilities, it is not possible to say that Mrs E would not have had a stroke even if she had not missed any of her regular medication. The hospital records show that Mrs E suffered another stroke while she was being treated in hospital. It is possible Mrs E would have suffered the first stroke even if she had not missed any medication.
  4. On this basis, I have not found that the failing here caused Mrs E any significant harm. Nevertheless, it is likely to have been a cause of distress for Mrs E while she was without medication, and a cause of stress for Mr M and his partner too. This is an injustice in its own right.

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Agreed actions

  1. Within one month of the final decision the Pharmacy should write to Mr M to acknowledge it did not manage Mrs E medication adequately in November 2016. Specifically, it should recognise it failed to order and deliver Mrs E’s medication at the end of November 2016, and did not take any other proactive steps to address any queries it had about this order with the Practice. The Pharmacy should apologise to Mr M for the avoidable distress this caused him and Mrs E.
  2. Within one month of the final decision the Pharmacy should pay Mr M £150 as a symbolic amount, to recognise the avoidable distress its fault caused him.
  3. Within one month of the final decision the Pharmacy should share a copy of the decision statement with all relevant staff. It should remind staff of the need to follow suitable policies, and to work proactively with other organisations to address any problems with medication it is managing for people.
  4. Within three months of the final decision the Pharmacy should review its policies for repeat prescriptions to make sure they include acceptable safeguards for times when it decides not to issue repeat prescriptions, and to ensure repeat orders are correctly diarised and acted on. It should make any changes that are necessary.

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  1. I have completed my investigation on following basis:
  2. There was fault on the part of the Council as carers should not have given Mrs E a dose of morphine which exceeded the prescribed dose. However, there is no evidence this caused Mrs E any harm or an injustice.
  3. There was fault on the part of the Practice as it did not handle Mr M’s request for a home visit properly. The Practice has already accepted this and taken fitting steps to address it. Therefore, there is no evidence of an outstanding injustice.
  4. It was fault that Mrs E’s regular medication ran out which, in turn, left her without it for three and a half days. The responsibility for ensuring Mrs E received her supply of medication on time lay with the Pharmacy. It is not possible to say Mrs E would not have suffered a stroke without this fault. However, it did cause Mrs E and Mr M stress which is an injustice in its own right.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman

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