Summary: Mrs D complained that a GP practice and nursing home failed to provide her father with medication he needed for four days and that this led to his death. The Ombudsmen find that both the GP practice and nursing home failed to make sure he received the medication on time, and this reduced his chances of surviving an infection. They have agreed to actions to address this.

The complaint

1. Mrs D complained about a delay in her father Mr P receiving medication prescribed by a GP from Dodworth Medical Practice (the Practice) on 1 September 2017. She said because of failures by the Practice and Saxondale Nursing Home (the Home), Mr P did not get the medication until 5 September. Mrs D believes this led to Mr P’s death on 10 September.
2. Mrs D seeks service improvements to ensure similar issues cannot occur again, an acknowledgement of what went wrong, and an apology for the impact of these failings.

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The Ombudsmen’s role and powers

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)). If it has, they may suggest a remedy.  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. 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 for both Ombudsmen. (Local Government Act 1974, section 33ZA, and Health Service Commissioners Act 1993, section 18ZA)
5. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
6. We may investigate matters coming to our attention during an investigation, if we consider that a member of the public who has not complained may have suffered an injustice as a result. (Local Government Act 1974, section 26D and 34E, as amended)
7. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended).
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
9. 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

10. I considered information provided by the parties to the complaint, including relevant records provided by the Practice and Council. I took account of relevant policy, law and guidance. I took clinical advice from an experienced GP.
11. I shared a draft of this decision with the parties to the complaint and considered their comments.

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What I found

12. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of the fundamental standards and prosecute offences.

Fundamental Standards of Care

13. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The CQC has issued guidance on how to meet the fundamental standards which care must never fall below.
14. Regulation 12 says providers must do all that is reasonably practicable to mitigate risks to the health and safety of the person receiving care or treatment. They must make sure those providing care have the skills and competence to do so safely. They must make sure people’s medicines are available in the necessary quantities at all times to prevent the risks associated with people not getting their medicines as prescribed.

Safeguarding investigations

15. Section 42 of the Care Act 2014 says that a council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.

The NMC Code

16. The Nursing and Midwifery Council (NMC) issued The Code in 2009 (updated 2015). This sets out standards of conduct, performance and ethics for nurses and midwives.
17. The Code says nurses should make sure care or treatment for which they are responsible is delivered without undue delay. They must make sure they accurately assess signs of worsening health. They should keep clear and accurate records of discussions, assessments, treatment and medicines given, along with how effective these have been.

What happened

18. A GP (Dr X) visited Mr P on Friday 1 September 2017. She recorded that Mr P was still chesty despite two courses of antibiotics. He was eating and drinking and not in respiratory distress. She prescribed antibiotics and steroids and decided to arrange a chest x-ray. She noted that the Home would seek help if Mr P got worse over the weekend.
19. Dr X said when she returned to the Practice she printed and signed the prescription and gave it to reception. The Practice’s records show it was printed at 14:32.
20. The Home said about 17:30 on 1 September a care assistant went to the Practice to collect the prescription, but a receptionist said it was not ready.
21. The Home said on 2 September the nurse put Mr P under close observation, which meant monitoring his oxygen saturation levels and wellbeing. It said the Deputy Manager instructed the nurse to contact 999 if Mr P got worse over the weekend. The Home said it had no concerns about Mr P over the weekend.
22. The Home said on 4 September the Deputy Manager contacted the Practice about Mr P’s prescription, and the receptionist said it was ready to be collected. The Deputy Manager asked the pharmacy to collect it. The pharmacy asked the Practice to fax it, and the Practice said it could not.
23. The pharmacy driver recorded that they tried to collect the prescription from the Practice in the afternoon of 4 September but the receptionist said it had not been signed.
24. On 5 September, the Home Manager contacted the pharmacy, which said it had tried to collect the prescription but it was not ready. The Home Manager contacted the Practice, and a receptionist said the pharmacy did not try to collect it the previous day, but it was now ready. They collected the prescription. They asked a GP to visit Mr P since he had not had medication all weekend. Mr P started getting the antibiotics and steroids that day.
25. On 7 September Mr P was admitted to hospital because he was more unwell, and he sadly died on 10 September. The hospital recorded that he died of aspiration pneumonia.
26. The Home raised a safeguarding alert with Barnsley Metropolitan Borough Council (the Council) on 9 September, and there was a safeguarding meeting on 27 November. There were representatives from the Council, pharmacy, Practice, Home, and family. Staff from the Practice asked the Home why it had not contacted the out of hours services to get a prescription in the evening of 1 September. The Home said it accepted it should have done this. Its staff had not known they could get out of hours help, and this had been addressed with them.
27. The Practice Manager said if someone comes to collect a prescription and it cannot be found, the usual process is for it to be reprinted, and he did not understand why this had not happened. One of Mr P’s daughters said the reception staff told them the prescription had been misfiled.
28. It was agreed at the meeting that the Practice Manager would reinvestigate what happened. Both the Practice and the Home would consider any training needs or improvements that were needed, and both would write to the family to apologise for what happened.
29. On 29 November, the Practice wrote an apology letter. It said the prescription had not been available due to “a human error in our administration team”, and it had “taken steps to minimise the risk of this happening again”.
30. On 3 December, the Home wrote its apology letter. It apologised that it had not contacted an out of hours service to get the prescription that the Practice failed to provide. It said it had learned from this, and now had a strict protocol in place for staff in similar circumstances.
31. Also on 3 December, a receptionist from the Practice wrote a statement which said she recalled that on 1 September Dr X did not bring all her prescriptions of the day out of her room until well after 5pm because she was running late. She said Dr X did not sign all her prescriptions that day, so some of them were “put forward for signing for Monday”. The receptionist said she recalled pharmacy staff coming to collect Mr P’s prescription on 4 September, but the prescription was not in the box for collection. The receptionist also said when the Practice Manager received a complaint about the delayed prescription, she witnessed him swearing about it and saying he would blame the Home.
32. There was a further safeguarding meeting on 22 January 2018. The Practice Manager said he met with staff on 6 December to discuss actions they needed to take and training needs. They agreed they should document on a patient’s notes when they gave out a prescription. If someone tried to collect a prescription which was not ready, and the clinician was unavailable, they would tell the person to come back and collect it at the end of the day. The Home said in future if it did not get a prescription it would contact the out of hours service for a short term one. It had also reviewed their procedures for handing over information at the end of shifts, and for documenting visits by GPs.

Findings

33. There is conflicting information about what happened to the prescription after it was printed on 1 September, and I cannot resolve this.
34. It is not in dispute that Mr P was prescribed the medication on 1 September, the prescription was printed, and a member of staff from the Home tried to collect it in the late afternoon. When the receptionists could not find it, they should have spoken with Dr X or the duty doctor to clarify whether the prescription was urgent, because it was for an acute condition. Since it was urgent, the prescription would then have been reprinted. The Practice was at fault here, on both 1 and 4 September.
35. The Home should have pursued the Practice further for the prescription, or contacted the out of hours service to get a new prescription, so Mr P got the medication on 1 September. It failed to do so.
36. The Home said it closely monitored Mr P’s condition over the weekend. This is not reflected in its records. The Home’s records contain very limited references to Mr P’s condition, but there are references in the care records to him being chesty on the days he should have had his medication but did not. The Home recorded his oxygen saturation levels, but did not monitor the other physiological observations it should have, such as his temperature, pulse and blood pressure. Therefore, I consider that nursing staff failed to properly monitor Mr P’s condition. Even if they had monitored him closely, this would not have been a substitute for making sure Mr P got his prescribed medication. In my view, the level of care the Home provided fell short of what is expected by the Fundamental Standards of Care and the NMC Code.
37. It is not possible to determine how likely it is that Mr P would have survived if he had received the prescribed medication on time. However, not getting it on time will have made it less likely that he would survive the infection. The uncertainty around this is an injustice to Mr P and his family.

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Agreed actions

38. The management of the Practice has changed since these events, and changes have been made at the Practice following this. The manager of the Practice at the time of these events has agreed to write to Mrs D within two months to acknowledge what went wrong, apologise for the impact of this, and explain improvements they made as a result. They will send a copy of this letter to the Ombudsmen. They will send a copy of this decision statement and its letter to Mrs D to its commissioning body and to CQC. They will supply evidence to the Ombudsmen that they have done this.
39. The new management team at the Practice will further review the Practice’s procedures to ensure all prescribing and reception staff are aware how to make sure patients get prescriptions for acute conditions when they need them. They will write to Mrs D within two months to explain what they have done. They will send a copy of this decision statement and their letter to Mrs D to their commissioning body and to CQC. They will supply evidence to the Ombudsmen that they have done this.
40. Within two months, the Home will work with the Council to review its practice and procedures for monitoring the condition of patients who are unwell and identify any required procedural changes or training needs. It will produce an action plan setting out how it will ensure that similar faults are prevented in future. It will write to Mrs D to acknowledge what went wrong and apologise for the impact of failing to ensure he got his prescription on time and failing to properly monitor his condition. It will explain what it has done to prevent similar events in future. It will send a copy of this letter to the Ombudsmen. It will send a copy of this decision statement and its letter to Mrs D to the Council, the CCG and to CQC. It will supply evidence to the Ombudsmen that it has done this.
41. Within two months, the Council will write to Mrs D to express its regret and to explain how it has worked with the Home and satisfied itself that sufficient improvements have been made to prevent similar faults happening again. It should copy its letter to the Ombudsmen and CQC.

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Decision

42. I find that:
1. The Practice is at fault for failing to make Mr P’s prescription available on both 1 and 4 September.
2. The Home is at fault for failing to ensure Mr P received the prescribed medication from 1 to 4 September.
3. The Home is at fault for failing to monitor Mr P adequately over this period.
4. The combined failures of the Practice and Home meant Mr P’s chance of surviving the infection was compromised, and this is an injustice to Mr P and his family.

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Investigator's decision on behalf of the Ombudsman