A practice in the City of Nottingham area

5. Mrs C complains about aspects of care and treatment her mother, Mrs F received from the Practice. Specifically, she says the Practice failed to monitor the condition of her mothers’ legs or provide appropriate treatment. She said she feels her mother should have been seen by a doctor, so they could see the condition of her mothers’ legs/feet. She is also unhappy with the way the Practice dealt with her complaint, as she feels it did not answer her concerns and there were significant delays.

6. She says her mother tragically died because of not being given the correct care and treatment and potentially may not have needed to go into hospital, causing her and the family a great deal of distress and upset. She also says lack of communication regarding the complaint caused her additional distress and upset.

7. She is seeking service improvements, a financial remedy and answers to her concerns.

8. On 24 March, Mrs F initially complained about pain in her foot. Between March and September 2021, she was monitored and seen by the Practice and district nurses. We have seen Ms F was receiving frequent input from various care providers including a local district nurse and cardiac nurses who do not form part of this complaint.

9. Mrs F had a face-to-face consultation with the Practice on 24 March and 16 June 2021, complaining of pain in her foot. On 16 June the Practice added dressing to the foot, and it was noted there was no sign of infection.

10. On 7 July, Mrs F contacted the Practice, asking for a review of her legs as they were painful. A nurse subsequently visited her the next day and assessed her legs.

11. On 20 July it was noted (by the GP) Mrs F had no signs of active infection. The main treatment for Mrs F’s legs at this time, was diuretics (a type of drug that causes the kidneys to make more urine) to reduce the oedema (swelling caused by fluid accumulation in body tissues) which was secondary to heart failure.

12. On 4 August 2021, Mrs F reported to the cardiac nurse that her legs were ‘leaking’, and the Practice arranged for them to be reviewed. Following this visit a referral was made to district nurses on 9 August 2021, and she was seen the next day (this appears to be when home visits started).

13. On 11 August 2021, district nurses completed a full holistic assessment and planned care of Mrs F. The assessment was detailed and covered factors that can impact on wound healing (nutrition, weight, mobility, pain, existing chronic conditions, home environment, sleep, falls, continence, communication).

14. During this visit a ‘small ulcer’ was noted on the side of Mrs F’s foot which was being cared for by podiatry (in the community), nurses planned care for this ulcer.

15. It appears following this initial assessment, the care continued with the Practice.

16. We can see on 3 September 2021 the district nurses asked the GP to assess Mrs F’s legs, to see if they would benefit from a steroid cream.

17. On 6 September 2021 the cardiac nurse discharged Mrs F from community care, documenting her legs were ‘pain free’.

18. On 12 September 2021, Mrs F was admitted to hospital following a fall at home.

19. On 29 October 2021, Mrs F sadly died following a stroke after a stay at hospital. Hospitalisation was due to sepsis caused by badly infected and ulcerated feet.

Treatment of Mrs F’s legs/feet

23. Mrs C has told us her mother was receiving treatment for her legs and feet by the Practice on an almost a daily basis and believes had she been seen by a doctor; she would have received appropriate treatment.

24. Following the initial assessment from the district nurses on 11 August 2021, the Practice assessed Mrs F the following day. The GP decided to stop furosemide (diuretic medication used to treat Oedema due to heart failure, liver scarring, or kidney disease) on this date due to Mrs F’s worsening kidney function.

25. Our Adviser explained this would have adversely affected the leg oedema and leaking, which we can see is noted in Mrs F clinical records on 20 August 2021, with ‘increased exudate (leaking)’.

26. Consequently, the Practice changed home visits to daily to account for the increased leaking. Our Adviser explained that Increased leaking in this case was due to heart failure and not a sign of infection.

27. They also explained the ulcer to Mrs F’s left foot did not require dressings from 18 August 2021. We can see nursing staff attended to Mrs F on a daily basis following the GP’s instructions which our adviser explained was appropriate and in line with NMC nursing standards 13.1 state:

‘Accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care’.

28. Our Adviser also noted that each individual home visit after 22 August 2021 the frequency of the visits was in line with the initial assessment and at all visits the legs and foot were assessed for signs of infection and deterioration. Mrs F was still being seen by the cardiac nurse.

29. On 26 August, the records indicate there was an improvement in the volume of leakage, as both Mrs F’s legs were ‘quite dry’.

30. On 27 August 2021, Mrs F was feeling unwell during the district nurse’s visit. The evidence suggests the social prescriber (a healthcare professional who helps patients address non-medical needs by connecting them with community resources and support services) visited at the same time as the nurse and discussed increasing social activities. Our Adviser said there was no signs of any deterioration in health at this time, and the signs were that Mrs F was improving.

31. On 31 August 2021, the GP saw Mrs F and it was noted during a telephone consultation on 2 September 2021, her legs were much drier, with no documented signs of infection.

32. In September 2021 photos of the wounds/ulcers on Mrs F’s feet and legs were taken. She had wounds to her left outer foot and under right foot and fourth toe.

33. Our Adviser explained the right foot and toe wounds were new. The GP had reviewed Mrs F the previous day, noting that her legs were ‘drying up.’ Mrs F was admitted to hospital on 13 September 2021 with infection to the left foot ulcer was suspected.

34. Considering the advice, we received and the evidence we have seen in Mrs F’s clinical records, we are satisfied the care provided by the Practice in respect to Mrs F legs and feet was appropriate and in line with guidance NMC guidance and there was no indication of infection prior to her hospital admission.

35. There is evidence of the Practice doing regular reviews, such as starting and stopping diuretics, assessing for steroid cream and checking for signs of infection. It does not appear there was any other concerns identified which would have warranted escalation to the GP other than the occasions she was seen by the GP.

36. We fully appreciate Mrs C’s concerns given the sudden deterioration in the condition of her mother’s legs/feet. It does not appear there were any signs of infection prior to her fall and admission to hospital. it is extremely unfortunate and saddening, but Mrs F appears to have been very poorly, and her condition does appear to have changed rapidly.

37. It is worth noting signs of wound infection, which were not documented by any of the clinician’s reviewing Mrs F include:

38. The NHS website says symptoms of an infected leg ulcer can include:

• worsening pain • a green or unpleasant discharge coming from the ulcer – redness may be harder to see on black or brown skin • redness and swelling of the skin around the ulcer • a high temperature (fever) • an unpleasant smell coming from the ulcer

39. There is no evidence that multiple different medical professionals identified any of these symptoms prior to her hospital admission. We appreciate Mrs C and her husband may disagree with what was documented, and we do not disbelieve them, but the weight of evidence from multiple sources means on the balance of probabilities we are satisfied there was no clear evidence of infection.

Complaint handling

40. We can see that Mrs C initially raised her complaint with the Practice on 14 December 2021. The Practice acknowledged it on 21 December 2021 and formally responded on 16 June 2022. Mrs C wrote back on 30 June 2022 and the Practice responded on 17 April 2024.

41. The NHS complaint regulations say the organisation investigating a complaint should ‘Investigate in a manner appropriate to resolve it speedily and efficiently’. The regulations say the organisation should send the complaint response 'within the relevant period', which it defines as 'the period of six months commencing on the day on which the complaint was received'. In this case it was 14 December 2021.

42. The regulations also state: ‘during the investigation the organisation should, keep the complainant informed, as far as reasonably practicable, as to the progress of the investigation’.

43. We can see the time between the Practice receiving Mrs C's complaint and sending its response was just over six months; however, there was a further delay of 22 months between receiving Mrs C's outstanding concerns and its final response letter.

44. The Practice accepted there were lengthy delays and has acknowledged its communication could have been better during this time (falling outside what is expected In the NHS regulations). During these two periods we would have expected the Practice to have kept Mrs C updated, especially given she contacted it on several occasions.

45. The Practice has told us at the time it received the initial complaint the member of staff responsible for dealing with complaints which contained clinical elements was on restricted duties due to illness. As a result, it says the complaint was a ‘casualty of this’.

46. It explained that a different clinical member of staff took over the complaint but due to limited resources the case took a while to review and complete. The Practice has acknowledged it should have done more to inform Mrs C during this time.

47. The Practice has said in the future it will try and resolve complaints it receives within a good timeframe. It has said it now has now put procedures and measures in place to ensure similar issues do not happen again in the future. It has said it now has a team lead in place to help with complaints and patients concerns.

48. Although, we appreciate the Practice has said it has taken steps to ensure similar issues with complaint handling do not occur again in the future, Mrs C told us that issues with complaint handling added additional distress and upset during what was already a deeply distressing time following her mother’s death.

49. Mrs C contacted the Practice again following its initial response, with additional questions and concerns.

50. The Practice failed to respond or keep Mrs C updated on several occasions, and when it eventually did it took 22 months. It is our view this falls below the expectations set out in the NHS Complaints Regulations (see above) and amounts to maladministration.

51. We appreciate the Practice (in its response on 17 April 2024) has apologised unreservedly for the delay and any additional distress caused to Mrs C and the family and can confirm it has also now also agreed to pay a financial remedy of £600.

52. This is in line with level three of our financial remedy scale. As such, we are satisfied the Practice has done enough to rectify the errors it has made. It has also reassured our office it has put measures in place to prevent similar issues from happening again in the future.

53. Mrs C has said the Practice failed to provide answers to her complaint. However, although there were delays in issuing its response, we are satisfied once the Practice did respond it answered in detail specific points Mrs C has raised.

54. Finally, we appreciate Mrs C may disagree with the responses provided by the Practice but from the evidence we have seen and based on our own conclusion on the clinical aspects of the case, we are satisfied the Practice have tried to answer the points she raised. This is in line with our complaint standards.

55. We hope our consideration of Mrs C’s complaint gives her the explanations she is seeking and will help bring her some closure to this traumatic time.

1. We have carefully considered Mrs C’s complaint about the Practice.

2. We understand this was a tragic experience for Mrs C and appreciate the distress and upset she has been caused due to the circumstances surrounding her mother’s death.

3. From the evidence we have considered, we have not seen any indications of failings in how the Practice treated Mrs F’s legs and nothing to indicate it failed to identify an infection prior to her hospital admission on 12 September 2021. However, we have identified delays in how it handled Mrs C’s complaint, but we are satisfied the Practice has now done enough to put things right.

4. For these reasons, we are not investigating further. We know how important this complaint is to Mrs F. We recognise the distress she has experienced which was clearly exacerbated by the handling of her complaint, and we appreciate her kindly sharing these details with us.