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Worthing Medical Group (21 000 200b)

Category : Health > General Practice

Decision : Upheld

Decision date : 01 Mar 2022

The Ombudsman's final decision:

Summary: We found fault by a care home acting on behalf of the Council regarding the care it provided to Mr X, an elderly man with complex care needs. We found the care home failed to support Mr X and his wife, Mrs X, to make an informed choice about his GP registration. We also found the care home failed to administer palliative medication to Mr X as prescribed. In addition, we found fault by the Practice as it failed to discuss Mr X’s end of life management plan with Mrs X. These failings caused Mrs X distress. The Council and Practice will apologise for this fault and take action to prevent similar problems occurring in future.

The complaint

  1. The complainant, who I will call Mrs X, is complaining about the care and treatment provide to her husband, Mr X, by Amberley Lodge Care Home (acting on behalf of West Sussex County Council) and Worthing Medical Group (the Practice) in March and April 2020. Mrs X complains that:
  • the care home arranged for Mr X to be registered with the Practice without informing her;
  • the care home and Practice failed to provide Mr X with appropriate care when he became unwell in April 2020;
  • the care home failed to tell her that Mr X had been tested for COVID-19;
  • a nurse at the care home made insensitive remarks to her about Mr X;
  • the care home and Practice failed to ensure Mr X was provided with appropriate palliative care. This included the care home’s failure to administer palliative medication to Mr X and the Practice’s failure to ensure he was provided with supplemental oxygen; and
  • the care home and Practice failed to arrange for Mr X to be admitted to hospital when his condition deteriorated in late April 2020.
  1. Mrs X says her husband was left without appropriate care and that she found this situation extremely distressing. Mrs X says the care home and Practice have provided her with inconsistent and contradictory accounts of what took place and have not been honest with her.

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The Ombudsmen’s role and powers

  1. 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).
  2. 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.
  3. 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. In making my final decision, I considered information provided by Mrs X and discussed the complaint with her. I also considered information provided by the Council and Practice, including the care home and clinical records. Furthermore, I invited comments on my draft decision statement from all parties and carefully considered the responses I received.

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What I found

Relevant guidance and legislation

GP registration

  1. The Social Care Institute for Excellence (SCIE) produces guidance entitled GP services for older people: a guide for care home managers. This guidance says that “[a] new resident should be involved, with their relatives where appropriate, in the decision about whether to remain registered with their current GP practice, or transfer to the list of a GP practice with which the care home has arrangements”.
  2. The guidance goes on to say that “[t]he home manager, together with the social worker or care manager, if one is involved, should take steps to help the resident and relatives make an informed decision.” This would include providing advice on the potential benefits and drawbacks of each choice.

Palliative oxygen therapy

  1. The term ‘palliative oxygen therapy’ refers to the use of oxygen to relieve symptoms of persistent breathlessness for people with life-limiting diseases.
  2. The decision on whether a person would benefit from palliative oxygen therapy rests with local specialist respiratory teams. If a respiratory team decides a person should have palliative oxygen therapy, the team will arrange a prescription through that person’s GP.

Acute oxygen therapy

  1. The British Thoracic Society produces guidance for the administration of acute oxygen therapy. This is entitled BTS Guideline for oxygen use in adults in healthcare and emergency settings (the BTS guidelines).
  2. Section 9.1 of the BTS guidelines emphasises the importance of early oxygen therapy for patients who are acutely breathless. The purpose of this therapy is to raise oxygen saturation levels in the blood to normal levels.

Key facts

  1. Mr X had complex health needs, including a history of stroke, diabetes and vascular dementia. He was admitted to the care home on 20 March 2020, following a hospital admission. The care home placement was arranged by the Council and funded by Mr X.
  2. On 20 April, care home staff contacted the Practice as Mr X was unwell. He had a raised temperature and a cough. The Practice advised the care home to contact Public Health England to arrange a COVID-19 test.
  3. The care home arranged a COVID-19 test for Mr X the following day.
  4. The care home contacted the Practice again on 22 April to report that Mr X had become ‘chesty’. A GP prescribed antibiotics to treat any underlying infection.
  5. On 23 April, the care home informed the Practice that Mr X’s condition was deteriorating. He was noted to be “pale and lethargic” and was no longer eating or drinking. Mr X was also refusing his medication. Following a telephone consultation, a GP prescribed palliative medication as he concluded Mr X was dying.
  6. Later that day, Mr X returned a positive test result for COVID-19.
  7. Mr X was admitted to hospital on 24 April. He died the following day.

Analysis

Practice registration

  1. Mrs X complained that the care home arranged for Mr X to be registered with the Practice without informing her
  2. The Practice explained that each care home has a GP surgery that is responsible for the care of its residents. The Practice said it is normal procedure for a person becoming resident in a care home to be registered with the GP surgery associated with that care home. This is to ensure the care home and GP surgery can coordinate effectively and provide continuity of care for residents.
  3. The SCIE emphasises the importance of supporting residents to make an informed choice about whether to remain with their own GP or transfer to the list of the GP surgery associated with the care home.
  4. I found no evidence in the records to suggest care home staff discussed this with Mr and Mrs X or supported them to make an informed decision. This was fault by the care home. This caused Mrs X frustration and distress.

Care for acute illness

  1. Mrs X said the care home and Practice failed to provide Mr X with appropriate care when he became unwell in April 2020. Mrs X said the Practice delayed in prescribing antibiotics.
  2. I understand there remains some dispute as to when Mr X first became unwell.
  3. The ambulance crew who transported Mr X to hospital on 24 April noted he had been coughing for two weeks by that time. This suggests Mr X began coughing around 10 April.
  4. The Practice notes of the telephone consultation on 20 April record that Mr X had been coughing for the past four to five days. This suggests an alternative onset date of 15 or 16 April.
  5. Mrs X said a nurse at the care home initially told her Mr X had started coughing on 13 April. She said the care home subsequently claimed the cough had not started until 17 April.
  6. I have reviewed the care home records in relation to this. There is nothing recorded in these records to suggest Mr X was unwell before 13 April. On that date, a nurse noted that Mr X “was lethargic and [kept] on leaning forward.” The nurse noted that she had spoken to Mrs X, though did not provide any details.
  7. The following day, the nurse noted that Mr X “was brighter today” and that he ate well. The same nurse made a similar note on 16 April, in which she wrote that Mr X was “bright the whole day” and had a good appetite.
  8. However, on 17 April, Mr X was noted to be coughing occasionally, had a raised temperature and was pale. The available evidence suggests Mr X did not become unwell until 17 April, therefore.
  9. Between 18 and 20 April, care home staff noted that Mr X continued to cough occasionally and that his temperature was still raised. This led the care home to contact the Practice on 20 April for advice. A GP concluded that Mr X may be suffering from COVID-19. He advised the care home to contact Public Health England to arrange a test. This was arranged for the following day.
  10. On 22 April, care home staff noted Mr X “appears frail…still coughing”. A member of staff contacted the Practice again for advice. There are discrepancies between the notes of the Practice and those of the care home for this consultation. The care home notes record that Mr X had tested positive for a urine infection and that the nurse practitioner prescribed antibiotics to treat this. However, the Practice’s notes make no mention of a urine infection. Rather, the Practice maintains that the nurse prescribed antibiotics to treat a potential chest infection.
  11. It is unclear why the care home note refers to a urine infection. I found no evidence elsewhere in the records to suggest care home staff completed a urine test for Mr X. I further note the Practice prescribed Doxcycline. This is an antibiotic that is commonly used to treat chest infections. On balance of probabilities, I consider it likely the reference in the records to a urine test was an error.
  12. Although care home staff first noted Mr X’s cough on 17 April, this appears to have been intermittent initially. There is no evidence to suggest Mr X’s condition deteriorated significantly over the following days. Nevertheless, when Mr X’s condition had not improved by 20 April, staff sought advice from the Practice. The care home then sought further input when Mr X was still unwell on 22 April.
  13. Overall, the evidence I have seen suggests the care home sought appropriate advice from the Practice when Mr X became unwell. I found no fault by the care home in this matter.
  14. Mrs X queries whether the Practice should have prescribed antibiotics for Mr X following the consultation on 20 April. This was ultimately a matter of clinical judgement for GP concerned. The Practice notes show the GP appropriately recorded Mr X’s observations in reaching a provisional diagnosis of COVID-19. As this is a viral infection, antibiotics were not indicated at that stage. I found no fault by the Practice on this point.
  15. However, during the consultation of 22 April, care home staff described Mr X as “chesty”. This suggested a change in Mr X’s presentation. The nurse practitioner concluded Mr X may also be suffering from a bacterial infection and prescribed antibiotics. Again, this was a matter of clinical judgement. Overall, the clinical records show the Practice was responsive to the change in Mr X’s presentation and prescribed medication appropriately.

Palliative care

  1. Mrs X complained that the care home and Practice failed to ensure Mr X was provided with appropriate palliative care. She said the care home failed to administer palliative medication to Mr X.
  2. On 23 April at 12.05pm, the care home contacted the Practice again as Mr X’s condition had deteriorated. The Practice notes record that Mr X was “pale and lethargic. Refusing meds, not really eating or drinking.” The GP recorded that Mr X’s blood pressure had risen and his oxygen saturation levels had dropped. The GP concluded that Mr X was at the end of his life. He prescribed palliative medication to make Mr X more comfortable.
  3. There is a further significant discrepancy between the records of the care home and those of the Practice with regards to this consultation. This relates to the medications Mr X was taking for his long-term health conditions.
  4. The member of care home staff who spoke to the GP recorded that he “ordered to [stop] all medications and prescribed End of Life Medications.” However, this is not reflected in the Practice records, which make no mention of an instruction to stop Mr X’s long-term medications. I would expect a GP to record an instruction of this nature in his consultation notes. It is unclear how this discrepancy arose. On balance of probabilities, I consider it likely this was a misunderstanding on the part of the care home staff.
  5. I am satisfied this did not have a significant impact on Mr X’s care. This is because he was admitted to hospital in the early hours of the following day. This meant he did not go without his long-term medications for any significant period.
  6. There is also confusion regarding Mr X’s palliative medication. The Practice records confirm the GP prescribed this medication at 12.10pm on 23 April, shortly after the telephone consultation. The care home’s controlled drugs register shows it received the medication later that day. The register does not record a time of receipt. It is unclear when the care home received the palliative medication, therefore.
  7. However, the records of the ambulance crew that took Mr X to hospital in the early hours of 24 April cause further confusion. The crew noted that “[e]mergency end of life meds have been arranged but are yet to be received by the care home…conveyed to emergency department as patient does not have end of life meds in care home and unlikely to be able to get hold of them in a good time frame to make the patient more comfortable.”
  8. The evidence I have seen shows the care home received the palliative medication for Mr X on 23 April. However, care home staff did not administer the medication as prescribed. It is of further concern that staff appear not even to have been aware that the medication had arrived when the ambulance crew attended on 24 April. This was fault by the care home.
  9. This situation caused Mrs X distress as Mr X was left in discomfort unnecessarily.

Oxygen therapy

  1. Mrs X also complained that the Practice failed to prescribe oxygen for Mr X when his breathing was laboured.
  2. It is important to be clear that there are two main types of oxygen therapy that are relevant here. The first is palliative oxygen therapy. This is used for patients nearing the end of their life who are experiencing ongoing breathlessness. This type of therapy would ordinarily be recommended by a specialist respiratory team and prescribed by a GP. As Mr X was not experiencing chronic breathlessness, palliative oxygen therapy was not clinically indicated. I find no fault by the Practice on this point.
  3. Oxygen therapy can also be used to treat acutely unwell patients. The care records show Mr X’s breathing was first noted to be “noisy, rapid but regular” at 1.30am on 24 April. Care home staff called for an ambulance and the attending crew administered oxygen shortly after their arrival at 1.45am.

Delayed hospital admission

  1. Mrs X complained that the care home and Practice failed to arrange for Mr X to be admitted to hospital when his condition deteriorated. Mrs X said she spoke to a nurse at the care home at 8pm on 23 April, who described Mr X as “greyish” and “drowsy”. Mrs X said the nurse held the phone to Mr X and that his breathing was laboured. Despite this, Mrs X said the care home did not call an ambulance until the early hours of the following day.
  2. The clinical records suggest the GP who completed the telephone consultation at 12.05pm on 23 April felt Mr X was dying. In its subsequent complaint responses, the Practice said the GP concluded hospital treatment would not be successful and was likely to be distressing for Mr X. As a result, the GP decided to focus treatment on making Mr X more comfortable in the care home. This was a matter of clinical judgement for the GP concerned.
  3. However, I found no evidence to suggest the GP discussed this management plan with Mrs X. This is evidence of poor communication and represents fault by the Practice. This caused Mrs X significant distress.
  4. There is no record of the telephone conversation Mrs X says she had with the care home nurse at 8pm on 23 April. I consider it likely, on balance of probabilities, that this call did take place. This is because Mrs X provided detailed recollections of the call. However, in the absence of any further corroborating evidence, I am unable to comment on what was said. Furthermore, I cannot say whether Mr X’s breathing was laboured at that time.
  5. I note the nurse who likely spoke to Mrs X at 8pm made an entry in the records at 9.15pm. She described Mr X as “frail and lethargic” but made no mention of laboured breathing at that stage. The care home records suggest that it was not until 1.30am on 24 April that Mr X’s breathing became “noisy, rapid but regular”. A nurse took Mr X’s observations. These revealed that his oxygen saturation levels had dropped to 83%. This was significantly below the normal range. This led staff to call an ambulance.
  6. The ambulance crew arrived at 1.45am and administered oxygen and pain relief before taking Mr X to hospital.
  7. Taking everything into account, I am satisfied the care home took appropriate action in calling for an ambulance when Mr X’s breathing became laboured. I found no fault here.

COVID-19 test

  1. Mrs X complained that the care home failed to tell her Mr X had been tested for COVID-19.
  2. The care home acknowledged staff did not inform Mrs X that Mr X had undergone a swab test. It said staff did not discuss the possibility of COVID-19 with Mrs X until 23 April when the test was positive. The care home apologised for this and said it would speak to staff to ensure this did not happen again.
  3. The care home should have advised Mrs X that Mr X had suspected COVID-19 and would be taking a test. It is not in dispute that it failed to do so. This was fault and caused Mrs X distress.
  4. I consider the care home’s apology to be a reasonable and proportionate remedy for the injustice caused to Mrs X by this fault.

Inappropriate remarks

  1. Mrs X said a nurse at the care home made insensitive remarks to her about Mr X during the telephone call at 8pm on 23 April. She said the nurse told her the hospital would not want Mr X and that he was “obstinate” and “stubborn”.
  2. As I have explained above, there is no record of the call Mrs X describes. While I understand Mrs X would have found any such comments distressing, I am unable to say, even on balance of probabilities, whether the nurse made the remarks Mrs X described.

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Agreed actions

Council

  1. Within one month of my final decision statement, the Council will:
  • apologise to Mrs X for the failure of care home staff to support her and Mr X to make an informed choice about Mr X’s GP registration. This caused Mrs X frustration and distress;
  • apologise for the failure of care home staff to administer palliative medication as prescribed by the Practice on 23 April. This meant Mr X was potentially left in discomfort, which was distressing for Mrs X; and
  • pay Mrs X £200 in recognition of the impact of this fault on her.
  1. Also within one month of my final decision statement, the Council will write to the Ombudsmen to explain what action it will take to ensure the care home has:
  • a robust procedure in place for supporting new residents to make an informed choice about whether they wish to register with a new GP practice; and
  • a robust protocol in place for the administration of palliative medications. This should include a process for receiving, storing, administering and recording palliative medications.

Practice

  1. Within one month of my final decision statement, the Practice will:
  • apologise to Mrs X for its failure to discuss Mr X’s end of life care management plan with her. This caused Mrs X unnecessary distress and confusion; and
  • pay Mrs X £100 in recognition of the impact of this fault on her.
  1. Also within one month of my final decision statement, the Practice will write to the Ombudsmen to explain what action it will take to ensure it has a robust procedure in place for end of life care management. This should include a clear process for discussing end of life care management with patients and their carers/relatives.

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Final decision

  1. I found fault by the care home (acting on behalf of the Council) with regards to its failure to support Mr and Mrs X to make an informed decision about Mr X’s GP registration. I also found fault by the care home as staff failed to administer palliative medication for Mr X.
  2. I also found fault by the Practice concerning its poor communication around Mr X’s end of life care.
  3. In my view, the actions the Council and Practice have agreed to undertake represent a reasonable and proportionate remedy for the injustice Mrs X experienced as a result of this fault.
  4. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman

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