The Woottons Surgery (17 019 357b)

Category : Health > General Practice

Decision : Upheld

Decision date : 18 Jun 2019

The Ombudsman's final decision:

Summary: Mr C has complained about the care and treatment of his late wife by a care home, GP practice and a trust. The Ombudsmen do not uphold the complaint with the care home or Trust, but have found fault with the Practice in relation to medication.

The complaint

  1. Mr C has complained about the care of his late wife, Mrs C, by a care home, Wyndham House (the Home) commissioned by Norfolk County Council (the Council), the Woottons Surgery (the Practice) and Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust (the Trust).
  2. Mr C has complained the Home:
    • Allowed his wife to get swollen ankles and feet
    • Gave his wife the wrong clothes to wear
    • Did not properly manage his wife’s nutrition, fluids and mouth care and hygiene
    • Did not have the required staffing levels
    • Did not allow him to visit his wife for seven days
  3. Mr C also considers the Practice inappropriately doubled his wife’s medication dosage and did not physically examine his wife
  4. He also says the Trust
    • Made his wife wait seven hours to see a doctor after arriving at hospital
    • Did not x-ray his wife’s nose
    • Allowed his wife’s fingernails to become dirty
    • Did not pick up on his wife’s mouth infection
  5. Mr C believes his wife’s death could have been avoided if not for the GP and the Home’s actions. Also, he feels the poor level of personal care meant his wife developed an infection in her mouth. Mr C says he suffered distress at witnessing these events. Mr C would like improvements to services so similar issues do not happen to others.

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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 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)
  3. 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.
  4. 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. During the course of this investigation I have considered the following evidence:
    • Telephone conversation and information supplied by Mr C
    • Information supplied by the Home, Practice and Trust
    • Independent clinical advice from a GP (our Adviser)
    • Care Quality Commission (CQC) guidance – Better Care in my Hands 2016
    • National Institute for Health and Clinical Excellence (NICE) British National Formulary (BNF) guidance on Lorazepam
    • NICE clinical guideline on dementia
    • I took into account of Mr C’s and the organisations’ comments on my draft decision before making this final decision

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What I found

Background

  1. Mrs C suffered from dementia and entered the Home in April 2017 for two weeks’ respite. Her condition deteriorated and she suffered falls, one of which on 1 May led to her being taken to hospital in the early hours of 2 May where she was diagnosed with a broken hip. She had a hip operation but sadly died shortly afterwards. Mr C made his complaint to the Home and the Practice and received a response before approaching the Ombudsmen in March 2018.

The Home

  1. Mr C was unhappy with the level of personal care provided to his wife by the Home. He said she was given the wrong clothes to wear, had swollen ankles and feet, dirty fingernails and received poor nutrition, fluids and mouth care. He was also unhappy about the staffing levels and the fact he was advised not to visit his wife for the first seven days of her stay. He said he was told this was to allow her to settle into the Home.
  2. The Home said there was evidence staff did try and manage Mrs C’s personal care but she was sometimes resistant to interventions. However, it admitted that personal care was not properly noted in the records. It said it found no record of Mrs C having swollen ankles or feet or that her nutrition and fluids were not managed appropriately. In addition, it found no record of Mr C being told not to visit for seven days.
  3. Following a critical CQC report and this complaint the Home outlined changes made which were:
  • ”New medication policies and procedures communicated to all staff dealing with medication
  • Introduction of house workshops delivered by the House Trainer on topics such as personal care, care planning and the importance of filling in documentation properly
  • Introduction of Observations of Direct Practice conducted by the House Trainer and the management of the Home to mentor and train staff in good quality care
  • Appointment of new General Manager and Deputy Manager of the Home
  • New care assistants and senior carers have been appointed and are closely monitored and supported
  • New monitoring procedure have been put in place to monitor quality of care such as new care plans with involvement of residents and relatives, daily monitoring forms, new handover forms and weekly reporting to the Regional Manager
  • The Home is heavily supported by the regional office to oversee quality of care and identify shortfalls to address them”
  1. With regard to not being able to see his wife for the first seven days I could not find evidence in the records of this being agreed with Mr C. However, the Home has said it is not a practice it currently adheres to. Therefore, I would not recommend any further action on this matter.
  2. The records show Mrs C’s fluid intake and nutrition was satisfactory and there were no concerns raised by staff during her stay. In addition, I did not find any reference to swollen feet or ankles or her wearing the wrong clothes although I accept Mr C did find his wife in this condition.
  3. Taking into account all the evidence, I have not found there were failings in care in relation to nutrition and fluid management. In addition, I have not found there was a fault leading to Mrs C having swollen ankles and feet. Due to the lack of evidence in the notes I will not pursue the matter of the wrong clothes any further. The Home has apologised for the failings it found in its own complaint investigation. Its action plan and increase in staff is comprehensive in ensuring care will improve for other patients. Therefore, although this was a very distressing time for Mr C and it is too late to help Mrs C, the Home has taken appropriate action to remedy the faults in its care.

The Practice

Inappropriately doubled his wife’s dosage and did not physically examine her

  1. Mr C said whilst in the Home his wife’s condition was deteriorating. He got a copy of the care home notes and found an occasion (20 April) when his wife was agitated and the care home contacted the Practice. Mr C said the GP told the Home to increase her dosage of Lorazepam without having seen his wife.
  2. Mrs C had two falls, the second one fracturing her hip. Mr C said the confusion and sedation caused by the drugs was the reason for his wife’s falls. He complained the GP should have visited his wife at the start of her stay to obtain a baseline of her condition and later when contacted by Home.
  3. The Practice stated that when the Home contacted the Practice on 20 April, the GP saw Mrs C was already on Lorazepam they felt what was needed was to increase the dose as a change of environment in a dementia patient can increase confusion and agitation. The Practice felt this was a reasonable course of action and it had planned to review Mrs C if necessary.
  4. The Practice said the next contact from the home was eight days later when a door was apparently broken by Mrs C due to agitation. It said it was clear the Lorazepam had not worked.
  5. The Home told the Practice it suspected a urinary infection. The Practice said antibiotics were the appropriate treatment to prescribe for this. However, the Practice admitted that a GP should have gone out to see Mrs C as the plan had been to review her if there was no improvement in her agitation.
  6. The Practice apologised for the shortfall in care. It changed its ways of working so that in future if there was sustained agitation in a patient then a face-to-face assessment should take place. In addition, adequate clinical information should be documented when a decision has been made. This should detail the reasons behind the decision and with an adequate plan as to when the patient would need review if no improvement.

Analysis

  1. The NICE guidance on Lorazepam says it should be used for challenging behaviour only on the advice of a specialist. Examples of specialists are “an elderly care psychiatrist, challenging behaviour team, or elderly care physician”. I have no found evidence such advice was sought in Mrs C’s case. The guidance also says dosage should be slowly increased with 2mg daily the maximum in exceptional circumstances.
  2. Mrs C was already on 0.5mg twice daily. The Practice on 20 April prescribed one or two tablets to be taken four times a day ‘when required’. The tablets were one milligram each. This could mean she could have up to eight tablets a day which could be four times the maximum dose. The care records state that from 20 April to 1 May Mrs C was given over the daily limit of two milligrams on seven different days. From the 27 April to 1 May Mrs C was given 3.5mg on 27 April and 3mg on each of the other days. This was significantly over the maximum recommended dose.
  3. In addition, this was not a slow increase as indicated by the guidance. In view of this it was fault by the Practice to prescribe Lorazepam with these instructions as it left it open to Mrs C being given too high a dosage by care staff.
  4. The NICE clinical knowledge summary on dementia lists Lorazepam’s most common side effects of drowsiness, dizziness and ataxia which could all increase risk of falls. Therefore, whilst we cannot say Mrs C would not have fallen if this fault had not occurred, it increased the risk of her falling.
  5. With regard to the lack of a home visit there was no obligation for the Practice to visit Mrs C when she was first moved to the Home. However, by 28 April matters had got worse and Mrs G had become very agitated. Medication had been increased but she was not getting better.
  6. GMC ‘Good Medical Practice’ point 16 indicates a doctor should examine the patient where necessary. It was apparent that Mrs C should be examined as her agitation was increasing. This was not done in this case which was fault on the part of the Practice. We cannot say this caused Mrs C’s falls but it was a missed opportunity to assess her more thoroughly and treat accordingly.
  7. Although the Practice has made some changes in relation to record keeping and visits, it has not properly addressed the fault over the over prescription of Lorazepam. This has not reassured Mr C that a similar situation will not occur in the future.

The Trust

Made his wife wait seven hours to see a doctor after arriving at hospital

  1. Mr C said after his wife was taken to hospital on 2 May 2017 they had a long wait of seven hours before seeing a doctor.
  2. The Trust has not responded to this issue. However, from the records I can see that Mrs C arrived at the hospital 01:37, was triaged at 03:10 and examined by a doctor at 05:57. This was not an undue delay on the Trust’s part.

Did not x-ray his wife’s nose

  1. Mr C said his wife was found to have fractured her nose due to a previous fall. However, he said that staff did not x-ray his wife when she was admitted on 2 May which led to a delay in the fracture being diagnosed. Mr C said this was especially of concern as his wife could have been suffering from a blood clot.
  2. The Trust did not respond to this issue. Furthermore, I could find no record of Mrs C suffering a fractured nose. There was a reference to a wound on her nose after her first fall in the Home, but no record in the GP or hospital notes of her suffering a broken nose. Therefore the evidence does not support Mr C’s belief his wife had broken her nose and I have not found fault on the part of the Trust.

Allowed his wife’s fingernails to become dirty

  1. Mr C said that there was a lack of personal care by Trust staff while his wife was in hospital which led to her fingernails becoming dirty. He felt this led to his wife’s mouth infection.
  2. The Trust did not respond to this issue. While there is no reference in the hospital records of Mrs C having dirty fingernails, I cannot conclude whether she did or did not. In the absence of available evidence, I will not pursue this issue further.

Did not pick up on his wife’s mouth infection

  1. Mr C said his wife had a mouth infection during her stay in hospital. This meant she refused food and drink as it was too painful. He complained the Trust did not pick up on the infection or treat it so that his wife’s nutrition deteriorated.
  2. The Trust said Mrs C had been diagnosed with oral thrush during her stay. This was treated with an oral spray as she refused mouthwash.

Analysis

  1. The Trust diagnosed Mrs C’s mouth condition and attempted to treat it. This was made difficult by the fact that quite often Mrs C would unfortunately refuse care interventions. I have not found fault with its treatment of Mrs C’s mouth condition.

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Recommendations

  1. I recommend that the Practice should within one month of this decision, write to Mr C acknowledging and apologising for distress caused by not knowing if his wife’s falls could have been prevented.
  2. Within three months of this decision, the Practice should provide evidence to Mr C of the actions taken to address the fault in relation to the prescription of Lorazepam and to prevent it from occurring in the future.

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Final decision

  1. I do not uphold this complaint against the Council or the Trust. In the Council’s case, the Home, acting on behalf of the Council, has taken sufficient action to prevent similar issues occurring in the future. I have not found fault with the Trust’s treatment of Mrs C. However, I have found fault with the Practice which it has not taken sufficient action to remedy.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman

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