A medical practice in the Luton area

4. Mrs O complains about the care GP at the Practice gave to her mother, Mrs I, from 21 to 28 May. She says the Practice:

· failed to put end of life medication in place (via a blue form) and did know how to follow the correct protocol

· failed to visit Mrs I at home while her condition was deteriorating, and did not respond to phone calls from Mrs O or various professionals regarding the need for a visit and medication

· incorrectly assumed Mrs I was in hospital and cancelled a needed prescription.

5. Mrs O says failings by the Practice meant her mother suffered unnecessarily and both she and her mother experienced unnecessary distress and inconvenience. She said she was also unable to stay in the area due to GP staff living locally and she would see them regularly, which was traumatic.

6. Mrs O is seeking an explanation as to what went wrong and financial compensation. She is also seeking service improvements, specifically for the Practice to train GPs about the blue form protocol.

7. On 21 May, a district nurse called the Practice to alert the GP to Mrs I’s declining condition. Receptionists at the Practice said a GP would return the call after 4pm. This did not happen.

8. Mrs O rang the Practice on 24 May to advise of her mother’s deteriorating health. The Practice did not return the call.

9. On 26 May, Mrs O contacted the Practice and spoke with the GP. Mrs O asked for a home visit. The GP asked if an end of life package was in place and was told it was not. The GP prescribed paracetamol syrup. The GP said they would visit in the next two days, but this did not happen.

10. On the evening of 27 May, a district nurse advised Mrs O to call an ambulance as they were concerned about Mrs I’s declining health. An ambulance attended and the paramedics felt Mrs I was sadly reaching the end of her life. The paramedics decided to leave Mrs I at home and arranged for an on-call GP to visit.

11. The on-call GP visited later that evening and left two prescriptions for pain relief. Once collected, the prescriptions needed to be administered by the district nurses. A district nurse sent a task to the GP on 28 May at 1.11am and advised Mrs I was reaching the end of her life. The district nurse requested end of life care to be put in place.

12. At 9am on 28 May, Mrs O’s husband went to the pharmacy to collect the prescription prescribed by the on-call GP, and a prescription for Buprenorphine (pain relief) patches. On arrival, he discovered the GP had cancelled the prescription for the patches.

13. Mrs O contacted the Practice, as Mrs I was in pain and agitated. The GP said they would send an electronic prescription to the pharmacy. Mr O visited the pharmacy again and spoke with the GP, who had also attended because they could not send the prescription electronically.

14. Mr O asked the GP why they had not visited, and a visit was arranged for 11.30am.

15. Later that morning, prior to the GP visit, the district nurse arrived for a home visit. They advised Mrs O they could not administer the injections prescribed by the on-call GP the previous day, as they needed a completed blue form in order to do this. The blue form allows the district nurses to administer injectable medication near end of life.

16. Mrs O rang the Practice to advise them of this and the GP arrived at 11:30am with the blue form. The district nurse told the GP they needed to scan and send the form to them as they could not administer the medication to the patient until this was done. The GP agreed to do this. The GP sent the blue form to the named nurse and contacted the district nurse centre, who confirmed it was in the nurse’s inbox.

17. At 5.42pm, Mrs O contacted the district nurse as no one had been to administer medication to her mother. The district nurse told her the GP had made a mistake on the blue form. This meant they could not administer medication. The district nurse told Mrs O to contact the GP.

18. At 5.50pm, Mr O contacted the Practice. The GP called at 6.05pm and said they would administer the injections themselves. When the GP arrived, Mrs I was agitated and distressed, due to being in pain.

19. Mr O asked the GP again why they had not visited earlier. The GP apologised. They admitted they should have administered the medication when they were there earlier, but they had asked a nurse to do this for him. Mrs I sadly died later that evening.

GP failed to visit Mrs I at home and did not respond to phone calls

23. As set out in the background above, the Practice was contacted by the district nurses and Mrs O on several occasions (21 May, 24 May, and twice on 26 May). The purpose of this contact was to request either a phone call or a home visit. The district nurses wanted to let the Practice know Mrs I was nearing the end of her life and would need relevant care.

24. The GMC’s Good Medical Practice says doctors ‘must provide a good standard of practice and care… where necessary, examine the patient, promptly provide, or arrange suitable advice, investigations, or treatment where necessary’. Our adviser tells us that a visit should have been done within a day or two after the GP was informed that Mrs I was near to the end of her life.

25. The Practice was first alerted to Mrs I’s declining health on 21 May. The GP did not visit Mrs I until 28 May. This is one week after the district nurses first alerted the Practice to Mrs I’s declining health.

26. Due to this evidence, we think there are indications the Practice failed to act in line with the GMC’s Good Medical Practice. The Practice should have visited Mrs I at home before the 28 May. In not doing so, it caused Mrs O unnecessary stress and distress in the final days of her mother’s life.

GP incorrectly assumed Mrs I was in hospital and cancelled needed prescription

27. On 15 May, the GP issued a repeat prescription for Buprenorphine patches (for pain relief). On 28 May at 1.11am, the district nurses told the Practice a paramedic had been called out, but that it was in the best interest for Mrs I to be cared for at home.

28. On the same day, Mr O discovered the Practice had cancelled the repeated prescription. The GP later explained they wrongly assumed Mrs I had been taken to hospital and acknowledged the Buprenorphine patches were still required.

29. The GMC’s Good Medical Practice says, ‘You must adequately assess the patient’s conditions, taking account of their history … promptly provide or arrange suitable advice, investigations, or treatment where necessary’.

30. By cancelling the prescription, it appears the GP did not follow the GMC’s Good Medical Practice as he did not consider the patient’s history. This documented Mrs I had not been taken to hospital. The GP also did not provide suitable treatment, by cancelling a prescription that was already in place.

31. After reviewing the evidence available, there are indications the Practice failed to act in line with the GMC’s Good Medical Practice. The GP should not have cancelled this prescription. By doing so it caused Mrs I to be in pain. It also caused further stress for Mrs O who had to contact the GP to re-arrange this prescription.

GP failed to put plans for end of life medication in place (via the blue form) and did know how to follow the correct protocol with regards to arranging for the District Nurses to administer medication

32. On 27 May, an out of hours doctor left a prescription for pain relief to be administered by district nurses. The following day, Mrs O contacted the district nurses who told her to request a medication authorisation form (blue form), from her GP. They explained this would allow them to administer this medication.

33. Mrs O contacted the Practice and requested the blue form. The GP provided a paper version of the blue form, but the district nurses were unable to accept this. The district nurses explained to the GP the form needed to be sent electronically. Although the GP later sent information electronically, the form was sent incorrectly.

34. The GMC guidance says doctors must plan as much as possible to ensure timely access to safe, effective care and continuity in its delivery to meet the patient’s needs.

35. Our adviser says standard procedure would be for the GP to prescribe the injectable medication, and either the pharmacy would deliver them, or the patient’s family would collect them from the pharmacy. The GP would also complete a drug chart which could either be handwritten or generated electronically and printed.

36. Both the drugs and the drug chart need to be present in the patient’s home for the district nurse to administer the medication. In some localities the drug chart may be electronic and not printed. In this case the district nurses required the blue form to be sent electronically to a specific inbox.

37. There should be an agreed process between the district nursing services and practices in the locality about what documentation is needed for the nurses to give injectable medication.

38. After looking at the evidence and reviewing what should have happened and what did happen, we think there are indications the Practice failed to act in line with the GMC guidance. We think the Practice should have known what to do to plan the care for Mrs O. Because it did not, there were delays in Mrs I receiving her medication, including pain medication.

39. This resulted in Mrs I being in unnecessary pain and distress during the last day of her life. Sadly, we think this could have been avoided.

40. We have considered the impact this had on Mrs O. During the last days of her mother’s life, Mrs O was under extra stress contacting the GP requesting home visits and prescriptions. Mrs O also had to witness her mother agitated and in pain due to not receiving pain relief in a timely manner.

41. In its response to the complaint, the Practice apologised for the distress Mrs O had suffered. It acknowledged the extra stress that this had caused Mrs O in an already difficult situation. The Practice also acknowledged its shortcomings and offered an unreserved apology.

42. Mrs O has asked for compensation for the distress caused and for service improvements. She wants the Practice to making sure it knows the correct procedure in how to implement the blue form, and that this is followed in the future.

1. We have carefully considered Mrs O’s complaint about a medical practice in the Luton area (the Practice). We were sorry to hear of Mrs O’s concerns about the care provided to her mother, and the distress these events have caused her.

2. We saw there were indications the Practice did not act in line with GMC guidelines when it did not put plans for end of life medication in place or visit Mrs O’s mother. We also saw indications of failings in the Practice incorrectly cancelling a prescription. We can understand why this was extremely distressing for Mrs O, and that it caused her mother, Mrs I, to be in pain.

3. We agreed a resolution with the Practice to put this right. The Practice agreed to pay Mrs O £500 compensation for the distress it caused. It also confirmed it has made changes to its processes for the future.

43. Before we decide to undertake a detailed investigation, we consider whether we can resolve a complaint without the need for a full investigation.

44. We can see the Practice has contacted the district nurses to find out the procedure for the blue form. The district nurses told the Practice the blue form needs to be sent to the named nurse, the admin team, and to the palliative care nurses, to ensure it was received.

45. The Practice has told us it is going to arrange a meeting with the district nurses to discuss a better way of working but did not want to do this while the investigation was ongoing.

46. We are satisfied the Practice now knows the procedure of how to implement the blue form procedure. We are also reassured the Practice is going to do further work with the district nurses.

47. On our severity of injustice scale, we think the impact on Mrs O falls into level three. Level three on our scale includes cases where there were failures in care which caused moderate distress or discomfort to the patient which added to the family’s bereavement after the patient’s death.

48. We think there is evidence Mrs O suffered additional stress and distress due to the actions of the Practice, at what was understandably an already difficult time for her.

49. We contacted the Practice and explained we thought it would be reasonable to provide a financial remedy in this case, and that we thought the injustice sat within level three. The Practice agreed to consider this and subsequently offered to pay £500.

50. We considered our Typology of Injustice. This stores information about some of the financial recommendations we have previously made, alongside details of the case. We consider this amount aligned with what we would recommend. Mrs O has also agreed to this amount.

51. Our Principles for Remedy say organisations should put things right. This means returning the complaint to the position they would have been and if this is not possible, compensating the complainant appropriately. Any remedy should be fair and proportionate to the injustice suffered.

52. Our Principles also say organisations should seek continuous improvement, using the lessons learned from complaints to ensure poor service is not repeated.

53. We were very sorry to hear of these events, and of Mrs I’s death, and the distress caused to Mrs O. We think the action already taken by the Practice and the financial remedy that has been offered are appropriate actions to resolve this complaint.