An independent provider in the City of Plymouth area

4. Mr R complains the Provider failed to appropriately action a referral for catheter (used to manage urine drainage in patients who cannot urinate naturally) support in February 2024. Specifically, Mr R says the Provider did not document or action the referral appropriately and did not communicate with him about his needs.

5. Mr R states due to the failings an obvious infection was allowed to develop further causing discomfort and distress, and he felt abandoned by the Provider. Mr R says the lack of support from the Provider meant he needed to seek urgent care from other local providers, which added to his distress and inconvenience.

6. Mr R is seeking service improvements and a detailed explanation of what led to the failure to act on the referral.

7. On 28 February 2024 Mr R was discharged from hospital following surgery. The hospital informed Mr R’s GP surgery that he had been catheterisation post-operatively, and this would need to be removed. Mr R’s GP surgery advised its practice nurses did not have the relevant training or expertise in this area. It therefore made a referral to the Provider on the same day, to ask the community nursing team (district nurses) to provide this support.

8. The Provider did not action this referral and on March 2024, after two days without communication, Mr R contacted his GP surgery asking for an update. The GP surgery made a further referral to the Provider by message and telephone. Mr R states he had informed the GP surgery there were obvious signs of an infection and he expected this to be communicated to the Provider.

9. After a further three days without communication, Mr R was concerned the infection was getting worse. On 4 March 2024, he contacted his GP surgery again. By the afternoon, Mr R felt more urgent action was required and took himself to the local community hospital. Mr R was unable to receive the care and treatment he required but a referral was made to the out of hours community nursing team.

10. During the evening 4 March 2024, Mr R was contacted by the out of hours service but there were long delays. Mr R therefore contacted his GP surgery the following morning. By the afternoon of 5 March 2024, Mr R was unable to wait for treatment and made his own way to the emergency department of his local hospital.

11. Mr R was treated at the hospital and returned home to find a phone message from the Provider offering a visit on 6 March 2024.

14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have found the Provider has already done enough to put right the impact of these events.

Failure to action a referral for care and treatment

15. Mr R told us the Provider failed to action the referral made to them for a district nurse to attend and remove his catheter. The referral was made on 28 February 2024 and the first time Mr R heard from the Provider was an answer machine message at 5:39pm on 5 March 2024.

16. We have seen evidence the GP Surgery made referrals to the Provider for a district nurse visit on 28 February 2024, 1 March 2024 and 4 March 2024. These referrals were made both by message and telephone call.

17. We note the Provider’s website references that it works closely with GPs and practice nurses. The website states anyone can contact the Provider about a referral. A telephone number for its switchboard is provided as the means of contact.

18. We note that the while the GP surgery and the Provider share the same building, they are two separate entities and therefore do not share computer systems.

19. The Provider investigated the complaint made by Mr R. In its initial response they accepted that the referrals had been made and accepted that the communication between the GP surgery and the Provider had gone wrong.

20. The Provider identified a ‘technical issue’ and ‘the systems used … did not communicate with each other’. The Provider stated it had implemented measures to prevent further occurrences and liaised with the GP Surgery to prevent future problems.

21. Mr R was not satisfied with the initial response from the Provider and asked for a review of his complaint. This was conducted by the community services manager, who met Mr R in person. The Provider provided a personal apology to Mr R for the delay in providing treatment and for the distress caused when Mr R felt ignored during the delay. It was agreed a further investigation would be conducted.

22. In a written response to Mr R, the Provider acknowledged referrals had been made from the GP surgery to the Provider. In particular, the Provider acknowledged the GP surgery had made a referral on 4 March 2024. The Provider acknowledged the referral had not been recorded and this was a failure on its part.

23. The Provider references the out of hours service contacting Mr R. The Provider accepts the out of hours service triaged the information provided by Mr R and made a referral to the Provider. The Provider accepts it was at fault by not contacting Mr R on the morning of 5 March 2024.

24. As we have seen indications of failings in the Provider’s care and service, we considered what action the Provider has taken to address this, in line with our Complaint Standards. These say organisations will use effective complaint handling to ‘see complaints as an opportunity to develop and improve its services and people’, to ‘set out what happened and whether mistakes were made’ and ‘take action to make sure any learning is identified and used to improve services’.

25. The Provider confirms changes have been made to the system for recording and triaging referrals. In the written response the Provider lists four changes to the referral process and one staff training outcome which have been implemented.

26. Mr R indicated his desired outcome was for the Provider to improve its service, to show its learnings and make changes to prevent any other patient going through a similar experience. It is our view that the Provider has met this outcome and communicated this to Mr R.

27. Mr R has informed us he is not satisfied with the response from the Provider, it has not identified the individual responsible for the failings and has not set out the actions taken to address the individual failings.

28. Our role is to investigate complaints about NHS organisations in England. In line with the Health Service Commissioners Act 1993, we cannot investigate complaints about individuals or personnel matters. This means we consider whether an organisation has acted in line with its role and responsibilities but would not comment on the actions of an individual employed by the organisation.

29. We consider the Provider has acted in line with its role and responsibilities in addressing Mr R’s complaint and taken action to improve its service. In the written response the Provider has identified system failures and made changes to address this. Additionally, the Provider has identified a training opportunity. For this reason, we will not be taking any further action on Mr R’s complaint.

1. We have carefully considered Mr R’s complaint about the care and service he received from Livewell Southwest (the Provider), who provide community nursing services in the Devon area.

2. Mr R’s GP surgery made a referral for community nursing support in February 2024. Mr R says this referral was not actioned appropriately, and he developed an infection. He says these events caused him distress and inconvenience, as he needed to access care from other services. We appreciate these events will have been very difficult as Mr R had also recently been discharged from hospital.

3. We can see the Provider has acknowledged the failings in the care and service it provided to Mr R and has taken action to improve its service. We consider these actions are appropriate to put right the failings we have seen. We therefore do not consider further action is needed in relation to Mr R’s complaint. We explain this further below.

30. We thank Mr R for bringing this complaint to the attention of the Provider. We recognise that Mr R has been through a distressing incident, which at the time caused considerable anxiety and physical discomfort.

31. Mr R’s persistence has led to real service change, and we thank Mr R for taking the time to bring this to our attention.