Portsmouth Primary Care Alliance Ltd

4. Miss G complains about the care and treatment Mr K received from the Practice between March and August 2020. Miss G complains that:

• the Practice failed to ask for the correct testing for Mr K’s urinary tract infection (UTI) until August 2020 • the Practice failed to collect Mr K’s urine samples using the correct methods • the Practice failed to give Mr K the correct medication to treat his UTI.

5. Miss G says the poor level of care and treatment the Practice provided to Mr K resulted in his death in August 2020.

6. Miss G wants acknowledgement from the Practice that it made mistakes in the care it gave to Mr K. Miss G also wants the Practice to make service improvements to stop this happening again.

7. Miss G also complains about the care and treatment that her grandfather Mr K received from PPCA in August 2020. She complains PPCA:

• gave Mr K the same antibiotics he had previously had side effects with, even though his son made it aware of this • failed to order a urine culture or sensitivity testing of Mr K’s urine.

8. Miss G says the poor level of care and treatment PPCA gave to Mr K caused in his death.

9. Miss G wants acknowledgement from PPCA that it made mistakes in the care it gave to Mr K. Miss G also wants PPCA to make service improvements to stop this from happening again.

10. Mr K was in his nineties and had a urinary catheter (a tube used to empty the bladder). In March 2020 his urine was cloudy, smelled bad and had blood in it. He also had pain in both sides and the back of his abdomen and was confused. The Practice asked for a urine sample for testing and gave him a prescription of antibiotics.

11. In June 2020 Mr K had symptoms of a UTI again and had swelling in both his lower legs. The Practice gave Mr K a prescription of different antibiotics and steroids.

12. Mr K’s son contacted the Practice in July 2020 about his father’s condition.

The Practice called Mr K’s son back and gave a prescription of different antibiotics.

13. A few days later Mr K stopped taking the antibiotics because they gave him side effects. Mr K’s son contacted the Practice to tell them.

14. The Practice visited Mr K at home almost two weeks later. He was feeling sick and dizzy, had a reduced appetite, was lethargic (tired) and the swelling in his lower legs made it difficult for him to walk. The Practice took a sample of Mr K’s urine for testing.

15. The Practice visited Mr K at home a few days later because he had possible cellulitis (a skin infection).

16. Six days later the swelling in Mr K’s legs was getting worse and his legs were covered in a rash. The Practice visited and gave him a prescription for antibiotics for possible cellulitis.

17. Almost a week later Mr K’s son contacted the NHS out of hours service at PPCA as Mr K had pain in both his sides as well as having chills and shaking. Mr K’s urine was cloudy and smelled bad. The PPCA gave Mr K a prescription of the same antibiotics the Practice had given him.

18. Miss G contacted the Practice two days later to ask for his urine to be tested. The same day a sample was sent to the microbiology department at a local hospital.

19. Mr K sadly died the next day.

21. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there are reasonable grounds to.

22. Miss G knew about the issues complained about in August 2020. That means to be within our time limit, she needed to come to us by August 2021. Miss G did not bring her complaint to us until April 2023, making it eight months late.

23. We can see Miss G complained to the Practice and PPCA in August 2020. The Practice responded to Miss G on 8 September 2020 and PPCA responded on 5 November 2020.

24. Miss G contacted NHS England on 19 October 2020. NHS England replied on 3 November 2020 explaining that as she had already complained to the organisations directly, it was unable to investigate her complaint. NHS England gave our details to Miss G.

25. Miss G contacted us on 10 November 2020 as she was unhappy with the responses from the Practice and PPCA. We closed the case as it was not ready for us because Miss G had contacted the Practice and PPCA asking for further responses.

26. We acknowledge that Miss G was within the 12-month time limit when she first approached us on 10 November 2020.

27. We can see the Practice sent a further response to Miss G but it does not have a date on it. We can see PPCA responded on 4 December 2020 explaining that it wanted to work with the Practice on a joint response, but communication had broken down between the two organisations. PPCA says it was unable to comment further about the Practice, but that it had responded to her separately by email.

28. Miss G returned to us on 11 December 2022 (25 months after her first contact) explaining that she had chased PPCA for a further response but had not received one. Miss G shared correspondence with us dated 9 August 2022 as evidence of her chasing PPCA for a further response.

29. We contacted PPCA on 12 December 2022 to ask if they were still investigating Miss G’s complaint. PPCA responded to us on 23 February 2023 confirming that it had closed Miss G’s complaint and issued its final response on 4 December 2020.

30. We contacted Miss G on 28 February 2023 explaining what the PPCA had told us and that we needed an updated complaint form from her for data security reasons. Miss G provided her completed complaint form on 9 April 2023.

31. The evidence we have shows us that before the correspondence dated 9 August 2022, Miss G last contacted the Practice by email on 2 December 2020. We needed to find out what happened between 2 December 2020 and 9 August 2022 to decide whether there were grounds to set our time limit to one side.

32. We emailed Miss G on 29 June 2023 to ask her why it took almost two years from the final responses in December 2020 to complain to us in December 2022.

33. Miss G told us during the pandemic she was juggling work(which included changing shift patterns as she worked in the NHS), home life and looking after her mother who was waiting for surgery for a dislocated hip replacement. Miss G also explained she was ‘suffering mentally’ but was not aware of it at the time.

34. Miss G explained she changed jobs in May 2022 and started to see a life coach as previous therapy she tried in 2021 was not helpful. She explained her mum had the surgery in August 2022. Miss G said this could explain why she started to take action with her complaint again in August 2022.

35. We are sorry to learn Miss G had a difficult time over the past three years and thank her for her honesty and for the information she provided. We do not wish to lessen the effect these matters have had on her.

36. We acknowledge the reasons provided by Miss G for the delay in returning to us. We have not seen good enough reason to put our time limit to one side.

37. While we can see that Miss G was having a difficult time in her life, she was still able to work on her complaint in November 2020 (when she first complained to us) and she would have been aware of the time limits from that contact with us as it is included on the complaint form she completed at that time. She had a final response by early December 2020. It seems reasonable to expect that she could have shared that with us earlier than December 2022.

38. We thank Miss G for providing us with the opportunity to review her concerns about the Practice and PPCA.

1. We have carefully considered Miss G’s complaint about the care and treatment provided to her grandfather, Mr K, by a practice in the Portsmouth area (the Practice) and Portsmouth Primary Care Alliance Ltd (PPCA). We are sorry to learn of the events that led to Miss G making a complaint. We offer our deepest condolences for her loss.

2. We have decided Miss G’s complaint falls outside the 12-month time limit and we have not seen good reason to put the time limit to one side.

3. We acknowledge that this is not the decision Miss G had hoped for. We do not wish to lessen the effect the events had on Miss G. We explain our decision below.