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North Swindon Practice Home Ground Surgery (20 011 171c)

Category : Health > General Practice

Decision : Upheld

Decision date : 18 Aug 2021

The Ombudsman's final decision:

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.

The complaint

  1. The complainant, who I shall refer to as Mrs B, complains about events which happened between December 2019 and January 2020 relating to her late father, Mr C. The complainant said Great Western Hospitals NHS Foundation Trust (the Trust) discharged her father from hospital but did not tell her or Orchid Care Home (the Home), which was funded by Swindon Borough Council (the Council), that it had diagnosed Mr C with a community acquired pneumonia. Mrs B said following a visit to her father in the Home a doctor from North Swindon Practice Home Ground Surgery (the Surgery) delayed in sending an electronic prescription for antibiotics to the local pharmacy. She complains the Home took too long to follow this up and did not contact out of hours services although it was aware her father needed the medication.
  2. Mrs B claims the events hastened her father’s death and as an outcome seeks a financial remedy for the loss of her father.

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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, 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)).
  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. I have considered information provided by Mr B, and information provided by the organisations named in this complaint.
  2. All parties were given an opportunity to comment on a draft of this decision.

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What I found

Law and guidance relevant to this complaint

  1. The Trust’s ‘Admission Transfer and Discharge of Adult Inpatients in the Acute Trust Policy’ provides the framework within which it will practice the safe and effective admission, transfer and discharge of its patients.
  2. NHS-funded Nursing Care (FNC) is the funding provided by the NHS to care homes with nursing, to support the provision of nursing care by a registered nurse for those assessed as eligible for NHS-funded Nursing Care.
  3. 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. (section 42, Care Act 2014)
  4. The Care and Support Statutory Guidance says, in order to respond appropriately where abuse or neglect may be taking place, anyone in contact with the adult, whether in a volunteer or paid role, must understand their own role and responsibility and have access to practical and legal guidance, advice and support. This will include understanding local inter-agency policies and procedures.


  1. Mr C was a permanent resident of Orchid Care Home from January 2014. The placement was arranged and funded by the Council via a deferred payment arrangement. This changed to full Council funding in 2016 and Mr B paid a contribution. The Home also claimed FNC Payments from the NHS.
  2. Mr C was admitted to the Trust’s hospital in December 2019 because his
    long term catheter was blocked. The Trust said he was admitted with oral medication (tablets) from the Home. During this admission it diagnosed Mr C with a pneumonia which was treated with intravenous antibiotics.
  3. On 21 December, a doctor examined Mr C and decided he was medically fit for discharge and well enough to return to the Home the same day. The Trust completed an Electronic Discharge Summary (EDS) which was printed and given to Mr C when he was discharged. The summary noted that Mr C had pneumonia.
  4. The Trust confirmed the procedure when a patient is discharged back to a care home. The nurse caring for the patient should contact the care home by telephone and give a detailed handover. This allows the care home to ask any questions and ensure they have all the information they need. The Trust said the nursing team telephoned the Home in line with its procedures, but it cannot find a record of the call. However, the Home’s records show it received a telephone call from the hospital on the discharge date.
  5. Mr C was discharged back to the Home with oral medication. Over the next two days carers noted Mr C had poor food and fluid intake and so contacted a doctor at the Surgery for advice. A doctor telephoned the Home on 23 December and said the antibiotics would be changed to oral suspension (liquid medicine). Oral suspension started the next day.
  6. The Home monitored Mr C over the next few days and although it noted he initially appeared better it said Mr C became lethargic. Although he responded to verbal communication, he did not open his eyes. On 1 January 2020, the Home asked a doctor from the Surgery to visit.
  7. A doctor from the Surgery went to visit Mr C on 2 January due to the concerns raised by the Home. At the time of the assessment the Surgery said Mr C showed no signs of abdominal distress and he was clinically stable. The doctor recorded that sounds in both his lungs suggested a current or recent chest infection which could have been from his recent pneumonia in hospital. The doctor concluded
    Mr C’s symptoms could be due to the persistence of his pneumonia and his abdominal distention.
  8. The doctor told the Home a prescription for antibiotics would be sent to the pharmacy. The doctor advised the Home to contact the Surgery or General Practitioner (GP) out of hours service if Mr C’s symptoms worsened. The doctor returned to the Surgery, updated Mr C’s medical record, and made an electronic prescription request for the antibiotics. This request should have gone directly to the pharmacy local to the Home.
  9. The Home said it did not receive the medication as expected from 3 to 5 January. The Home contacted the pharmacy which confirmed it had not received the prescription. The Surgery was closed at this time as it was the weekend.
  10. The Home contacted the Surgery on 6 January to report it had not received
    Mr C’s medication from the pharmacy. A doctor at the Surgery checked and realised the electronic prescription request had not sent. The doctor generated a prescription immediately and Mr C received the medication on the same date.
  11. A doctor from the Surgery reviewed Mr C on 7 January. The doctor noted Mr C was comfortable, clinically stable and that his appetite and intake was improving. Unfortunately, Mr C died later the same evening.
  12. The Home said the events did not meet the criteria to make a safeguarding alert to the Council.

Mrs B’s complaints to the Trust, the Home and the Surgery

  1. The Trust responded to Mrs B’s complaint in January 2020 and said its clinical team had documented Mr C as having a community acquired pneumonia. When it assessed he was medically fit for discharge the nursing staff gave a handover to the Home before Mr C returned. It said the nursing documentation did not reflect nursing staff confirmed Mr C’s diagnosis of community acquired pneumonia to the Home.
  2. When the Home responded to Mrs B’s complaint it said there was no change in Mr C’s clinical presentation during the period the medication was delayed. The Home accepted it should have chased up the delayed prescription sooner. It said as the events occurred over the weekend it could not contact the Surgery. It confirmed it had changed it processes to avoid similar mistakes.
  3. The Surgery responded to the complaint and said its usual practice was to print a paper script and arrange for it to go to the relevant pharmacy. As the pharmacy was not local the doctor sent the prescription electronically. However, although the doctor believed the prescription was sent it was not due to a technical error. The Surgery confirmed the doctor had reviewed the guidance on how to send electronic prescription to improve practice. The Surgery also said it also highlighted a need for better communication between care homes and surgeries to ensure that when prescriptions are not received within a given timescale the matter is escalated.
  4. NHS England also responded after it had looked at the complaint to the Surgery independently. It partly upheld Mrs B’s complaint because an error occurred where the prescription was not released. It said, ‘There remains work to do about care homes and pharmacies communicating with practices when this occurs as a GP cannot rectify what they do not know’.

The Council’s involvement

  1. The Council funded Mr C’s placement in the Home but the Home also claimed FNC payments from the NHS. The Council was not involved in the events which occurred as the Home did not alert the Council to Mr B’s admission into hospital and subsequent discharge. However, because the Council was funding the placement it is responsible for the actions of the Home.
  2. The Home or the Surgery did not alert the Council to the concerns relating to the delayed prescription. Therefore, the Council could not consider the matter in line with its safeguarding responsibilities. Mrs B did not complain to the Council.
  3. The Council said, in retrospect, if either the Home or the Surgery had raised a safeguarding concern with its Safeguarding Team it would have considered the statutory criteria for a Section 42 Enquiry to have been met. It would have had a duty to undertake a Safeguarding Enquiry into the concerns.


The actions of the Trust

  1. The Trust confirmed it has no record of the telephone call its nursing staff made to the Home when Mr C was ready to be discharged. Therefore, it cannot confirm whether nursing staff verbally told the Home full details about Mr C’s diagnosis and any other relevant information. This is poor practice and I find the Trust at fault. However, it is evident a telephone call was made to the Home on the day of discharge and likely, on balance, handover information was provided by telephone but not recorded.
  2. The Trust also discharged Mr C with a copy of EDS written discharge summary. Therefore, Home had written information to refer to and it could have contacted the Trust if it had any queries or concerns once Mr C was discharged. The Trust’s fault identified is unlikely to have caused injustice to Mr C.
  3. In response to our enquires the Trust said it recognised that its discharge information and handovers are not always as detailed and complete as they should be. It said it is undertaking quality improvement work to review patient admission and discharge documentation to make improvements which are clinically led, patient centred and improves communication. It is not necessary for us to make further recommendations.

The actions of the Surgery

  1. The error the Surgery made with the electronic prescription was fault. NHS England found fault and therefore the Surgery accepted it was at fault before
    Mrs B complained to the Ombudsmen.
  2. Although the Surgery delayed in sending the electronic prescription to the pharmacy it could not have acted to put things right sooner than it did. The Home did not tell the Surgery there was a problem until after the weekend.
  3. Mrs B claims the delay in the medication being received hastened her father’s death. When a doctor reviewed Mr C after the issue came to light there was no indication his condition had worsened since the previous visit by the doctor a few days earlier.
  4. The Surgery confirmed that the doctor who made the request was still undergoing GP training. As a result of Mrs B’s complaint, it has acted to improve. GP Trainers in the Surgery now ensure that Trainees understand the correct processes for electronic prescribing. This is covered as part of the Surgery’s induction for new GP Trainees. Therefore, a further recommendation is not necessary.
  5. The Surgery confirmed it reported the matter to the NHS National Reporting and Learning System as a ‘Patient Safety Incident’. The Surgery should also have reported the matter to the Council as a safeguarding concern in line with its wider safeguarding responsibilities. As it did not do so it is at fault and it is likely this contributed to a missed opportunity to instigate safeguarding procedures.

The actions of the Home on behalf of the Council

  1. The Home recorded a telephone call with the nursing staff before Mr C was discharged. The note is brief and does not provide much detail about what the discussion was about. This poor recording of information is fault. The Home also had a responsibility to glean information from the nursing staff at the hospital and record details properly.
  2. The Home said the Trust did not say Mr C had pneumonia during the handover telephone call. I cannot say what information was provided during the verbal handover, but the information about pneumonia was recorded in the EDS received by the Home.
  3. The Home should have taken immediate action as soon as it became aware there was a delay in Mr C receiving his antibiotics. This should have been from the latest 3 January 2020. The Home could have contacted the pharmacy sooner or the Surgery directly. The Home said it could not contact the Surgery as it was the weekend. However, the Home could have contacted the out of hours GP service for further advice rather than waiting until after the weekend to contact the Surgery. The Surgery could not have reacted sooner than it did as it was not aware of there was a problem.
  4. The Home’s notes record no change in Mr C’s presentation during the period of delay. Therefore, I cannot say the delay in receiving medication caused his untimely death.
  5. The Home did not report what happened to the Council as a safeguarding concern and told us that it did not meet the criteria. However, the Council which has statutory responsibility for safeguarding does not agree with this view. It said it would have considered the matter under its safeguarding procedures as the threshold would have been met. The Home could have contacted the safeguarding lead for advice but did nothing. I find the Home at fault. As a result, it is likely that Mrs B missed an opportunity to have events which she blamed for her father’s death investigated under safeguarding procedures. This may have provided her with further clarity or helped to minimise her doubts about what happened.
  6. The Home now has a new Manager who has acted to improve since being in post. The Home said it has changed it processes to ensure medication is chased if not received. It has also contracted with a new pharmacy which it says is more reliable. It is not necessary to make a further recommendation in this regard.

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Agreed Recommendations

  1. Within one month of the Ombudsmen’s final decision:
    • the Council will monitor the Home to ensure it acts to improve how it records information during verbal telephone handovers with hospitals. The Home will develop a form to use if necessary.
    • the Council will ensure the Home reviews its safeguarding procedures in conjunction with the Council’s Safeguarding Adults Threshold Guidance. If required, the Council will provide further advice or training to the Home.
    • the Surgery will review its safeguarding procedures and remind its staff of the importance of reporting incidents relating to patient safety to the Council’s Safeguarding Team in addition to other relevant agencies.
  2. Both the Home and the Surgery will write to Mrs B and apologise for the injustice she experienced because they did not report the incident to the Council so it could consider a safeguarding enquiry.

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Final decision

  1. The Council, the Home and the Surgery have agreed to our recommendations and so I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman

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