A practice in the Trafford area

Complaint about the Practice

3. Miss R complains that between April 2020 and December 2021, the Practice delayed replacement of her mother, Mrs R’s, ring pessary. She says these delays likely resulted in her mother having vaginal bleeding and UTIs which required antibiotics.

Complaint about the Trust

4. Miss R complains that from around September 2020, the Trust refused to provide her mother with incontinence briefs and would only provide pads, even though briefs were most suitable for her.

5. She says it unnecessarily repeated continence assessments and tests in January 2021, even though they had only been done 12 months earlier.

6. She says these tests were uncomfortable and confusing for her mother, who, due to dementia, would not know what was happening. She says the use of incontinence pads rather than briefs was uncomfortable for her mother and may have led to her having UTIs which required antibiotics.

Both organisations

7. Miss R says the repeated UTIs and antibiotics are likely to have weakened her mother’s immune system and reduced her ability to fight COVID-19 infection. She says this may have contributed to her death on 4 January 2022.

8. She says these events were frustrating for her and distressing for her mother.

9. In bringing the complaint to us, Miss R is seeking service improvements so other patients do not experience the same problems.

10. Mrs R moved into a residential home (the Home) in the Trafford area in April 2020, having previously been cared for at home by her daughter, Miss R. On moving into the Home, Mrs R was registered with the Practice.

11. Mrs R had for many years had a vaginal pessary for uterine prolapse. This is where there is slipping or sagging of the uterus from its original position. A pessary ring fits into the vagina to support the prolapse. These are routinely changed every six months. Mrs R’s pessary was due to be changed at the end of May 2020.

12. Mrs R was unexpectedly admitted to hospital on 10 July. During that admission gynaecology team changed the pessary for her. A GP at the Practice changed the next pessary for Mrs R on 23 February 2021.

13. In November 2021, the Practice referred Mrs R to gynaecology services to change the pessary. They arranged an appointment for January 2022. This never happened as sadly Mrs R was admitted to hospital with COVID-19 and died on 4 January 2022.

Complaint about the Practice

17. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

18. IUGA guidance published in April 2020 says that although the most popular practice is to change the pessaries every six months, it would be reasonable to delay it for up to a further three months.

19. The joint guidance published in April 2020 says all routine ring pessary changes may be delayed for three months in the first instance up to a maximum of six months from when the last change was due.

20. Mrs R’ pessary was due to be changed at the end of May 2020. The Practice was aware of this and was willing to do this in the Practice. Miss R had requested it be done at the Home, but the GP declined due to inadequate facilities for this compared to at the Practice. The GP advised that Mrs R could attend the Practice or alternatively delay the change for three months.

21. The Practice arranged an appointment for 24 July. This would have been approximately eight months since the last pessary was changed. This was in line with the IUGA and joint guidance. In any event, as set out in paragraph 16, the pessary was changed a little earlier on 15 July during an admission to hospital.

22. A GP at the Practice changed the next pessary on 23 February 2021. This was seven months and eight days since the last one. This was in line with the IUGA and joint guidance.

23. In October, the Practice had discussions with Miss R about the next pessary change which was due. Although the Practice initially incorrectly sent a referral to the wrong department, this was corrected, and they made a referral to gynaecology department in November. Once the referral was made, the timing of the appointment was outside the Practice’s control.

24. We can see that the gynaecology department at the local hospital arranged an appointment for this to be done in early January. This would have been just over 10.5 months since the previous change. Therefore, we can see that despite the initial error in relation to the referral, the timing of the ring pessary change was not outside the recommended timescales. The Practice had referred Mrs R so that it could be changed in line with the joint guidance.

25. As the timing of Mrs R’ ring pessary changes were in line with the guidance in place at the relevant times, we have seen no indication the Practice did anything wrong. For that reason, we will take no further action.

Complaints about the Trust

Continence assessment

26. As set out in paragraph 21, we have compared what did happen against what should have happened. Having done so, we have not found any indication something went wrong.

27. The ACA guidance says all adults who suffer with urinary or faecal incontinence should undergo a comprehensive assessment. It says reassessment of product provision should be done annually, as a minimum.

28. It says when there is transfer between service areas, if products or quantity differs and the patient has not had an updated clinical assessment in the last six months, the patient will have to have a new clinical assessment.

29. Although we do not know the date, evidence from Miss R is that her mother had a continence assessment done in 2019.

30. Mrs R was referred to the Trust in August 2020, which was at least eight months since her previous assessment. The Trust had a discussion with Miss R about her mother’s products and sent a questionnaire to the Home for it to complete.

31. There is evidence from Miss R and the records that staff at the Trust told her the Trust does not provide pull up incontinence briefs. Although we have not seen the contract, the Trust has confirmed to us that it is not commissioned by the CCG to provide these products.

32. CCGs were NHS organisations who, at that time, were responsible for planning and commissioning health care services for their local area.

33. We can see that as there would be a change of product when moving into the area, and it had been six months since the previous assessment, it was line with the ACA guidance to complete a new clinical assessment of Mrs R continence.

34. Further, by the time the assessment was done in January 2021, it was 12 months since the previous assessment. Therefore, irrespective of the products available to the Trust, it was in line with guidance to complete a further assessment.

35. There are no indications of failing here which means we do not need to take any further action.

36. We appreciate Miss R is worried about how going to a clinic for a further assessment affected her mother, as she had previously found it confusing and distressing. We would like to reassure Miss R that the Trust staff attended the Home to complete the assessment.

Provision of products

37. Miss R is unhappy that Trust refused to provide her mother with incontinence briefs. We acknowledge Miss R is frustrated by the change of products as she had previously found these were effective for her mother.

38. Miss R concern is that the provision of continence pads rather than pull up pants led to her mother having repeated UTIs which may have contributed to her death.

39. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right.

40. Mrs R’ GP records show she experienced UTIs in July, August and November 2020 and January 2021. These were before the Trust began providing pads, which was on 2 February 2021. Once the Trust began providing continence products to Mrs R she had two further UTIs, in July and December 2021.

41. We appreciate that the frequency of her mother’s UTIs is concerning for Miss R. The ACA guidance explains that UTIs are common in older women.

42. The majority of UTIs Mrs R experienced were before the Trust began providing pads, when Mrs R was wearing pull up pants. This means we cannot link the provision of incontinence pads by the Trust to Mrs R having UTIs. As such, we cannot say this may have contributed to her death.

43. Turning to Mrs R comfort, we have seen no evidence so far to indicate Mrs R found the use of these products uncomfortable. There is no evidence that staff from the Home or Miss R contacted the service to inform it that the products being provided were ineffective or causing any difficulties.

44. As we cannot see any indication the provision of products had any negative impact on Mrs R, we will not consider this issue further.

45. We hope the explanations we have provided about her mother’s care are reassuring for Miss R.

1. We have carefully considered Miss R’s complaint about the care the Practice and the Trust provided to her mother, Mrs R. We know how strongly Miss R feels about this complaint and we thank her for bringing her concerns to us.

2. Having considered the complaint, we have seen no indication anything went wrong in the timing of the Mrs R’s ring pessary change or in the continence assessment. We have decided we cannot link the provision of continence pads to Mrs R having urinary tract infections (UTIs). We explain how we have reached these views below.