The Surgery
30. We appreciate how concerned Mrs Q is about the medication administered by the Surgery to her son, when he attended on 25 August 2023, especially given he later developed Steven Johnson syndrome. She has told us the Surgery prescribed penicillin without considering her son’s medical history.
31. Mr P’s medical records do not suggest he had any allergy to penicillin. He also verbally confirmed this on the day of his consultation on 25 August with the Nursing Practitioner. It is recorded that Mr P had diabetes and was on dialysis for kidney disease and ‘he was dialysed yesterday’.
32. Our nursing adviser explained Mr P’s symptoms on the day were in line with acute tonsilitis (acute sore throat) and penicillin V (phenoxymethylpenicillin) is the first line antibiotic for this condition. This is in line with local primary care antimicrobial guidelines for patients who do not have a penicillin allergy, such as Mr P.
33. Furthermore, NMC guidance states nurses should:
• understand the principles of safe and effective administration and optimisation of medicines in accordance with local and national policies and demonstrate proficiency and accuracy when calculating dosages of prescribed medicines • demonstrate knowledge of pharmacology and the ability to recognise the effects of medicines, allergies, drug sensitivities, side effects, contraindications, incompatibilities, adverse reactions, prescribing errors and the impact of polypharmacy and over the counter medication usage.
34. BNF guidance on ‘Phenoxymethylpenicillin’ does not list diabetes or kidney disease as conditions that need to be considered when administering the drug.
35. Given the evidence we have seen, we are satisfied the Surgery acted appropriately and in line with relevant guidance when prescribing Mr P with phenoxymethylpenicillin on 25 August.
36. The Surgery appropriately considered Mr P’s presenting symptoms, medical history and allergy status. This is in line with NMC code of professional standards
37. We do appreciate Mr P did sadly later developed Steven Johnson Syndrome, but we cannot say this was due to the actions of the Surgery. As such, we have not upheld the complaint against the Surgery.
The Centre
38. Mrs Q raised concerns about the decision of the Centre to prescribe her son further antibiotics on 26 August 2025, stating it failed to consider his medical history and presenting symptoms. She also says the Centre wrongfully diagnosed Mr P and should have admitted him to hospital.
39. From the evidence available, Mr P was seen by a General Practitioner (GP), who took his medical history. It was recorded Mr P had attended his GP surgery with complaints of a sore throat and been prescribed phenoxymethylpenicillin.
40. Our GP adviser explained that it was clear the antibiotics previously prescribed by Mr P’s GP Surgery were not working, given his symptoms had not improved.
41. Our GP adviser explained Mr P had inflammation and spots in his throat and explained his antibiotics were changed to an alternative (clarithromycin) which would help treat any infection Mr P may have had. This is in line with BNF guidance on the use of clarithromycin for treating acute sore throats.
42. Our GP adviser explained the GP took a full history of Mr P’s symptoms, carried out an examination and took his vital signs before reaching a conclusion on his diagnosis.
43. He explained there no indication to suggest the Centre should have referred Mr P to hospital on 26 August 2023. The decision to admit Mr P would have been made on how unwell he presented at the time.
44. All vital signs (temp/observations/heart rate/blood pressure) were taken and there was nothing to suggest he should have been referred. Based on the evidence recorded Mr P’s vital signs were not abnormal enough to suggest illness serious enough for him to be admitted to hospital.
45. GMC GMP guidance says clinicians must provide a good standard of practice and care, and if they assess diagnose or treat patients, they must: • ‘adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs’.
46. Based on the on the evidence we have seen and given the relevant guidance we are satisfied the Centre acted appropriately when treating Mr P and administering medication on 26 August 2025. However, we again, appreciate given the severity of Mr P’s condition a few days later, why Mrs Q may feel the Centre should have referred her son to hospital sooner.
47. We have not seen any evidence to suggest the change of antibiotics was incorrect or outside national guidance. As such, have not upheld the complaint against the Centre.
The Trust
48. Mrs Q raised concerns about Mr P suffering a fall when using the commode on 2 September. The Trust explained in its response that Mr P suffered an unwitnessed fall. It was noted the nursing staff did not re-engage the rear brakes of the bed, and it was deemed this may have been a contributing factor in Mr P’s fall.
49. Given it is accepted the Trust failed to apply brakes we looked at whether appropriate steps were taken to mitigate the risk against Mr P falling.
50. We can see the Trust carried out an initial risk assessment on 28 August. This was prior to Mr P’s fall. However, our nursing adviser explained the Trust should have carried out another risk assessment once Mr P suffered a fall. This is to ensure fall prevention measures were put in place. It appears this was not done.
51. NICE guidance falls: assessment and prevention recommends: • In all settings (community, hospital inpatient and residential care), discuss ways that people can reduce their risk of falls as well as improving their overall wellbeing, and provide information that they can take away.
• That a person's risk factors may change when they are in hospital.
• How to move around safely and stay as active as possible while in hospital, and when and how to seek help (for example, if they need to call for assistance to go to the bathroom).
• How to use unfamiliar equipment during their admission, for example, bed controls and the call bell.
• Offer a comprehensive falls assessment and comprehensive falls management to people in hospital inpatient settings and residential care settings.
• Include the following assessments and examinations (where appropriate) in the comprehensive falls assessment to identify the person's individual fall risk factors: 52. The care plan dated 28 August identifies a commode at Mr P’s bed and assistance from one staff member was noted. It appears at the time of the fall, Mr P requested assistance to use the toilet. The nurse on duty at the time appears to have assisted Mr P but left whilst he used the toilet. During this time, he sadly suffered a fall.
53. Although, it is unclear what happened when the nurse left Mr P to use the commode it does appear there was a human error which resulted in the brakes not being applied to his bed. Given the significance of the error, we consider at this to be a failing.
54. The Trust has explained it shared learning at the nursing safety briefing and the incident has been discussed at the relevant governance meetings.
55. This is in line with NHS complaint standards, which state: ‘Organisations support and encourage staff to be open and honest when things have gone wrong or where improvements can be made. Staff recognise the need to be accountable for their actions and to identify what learning can be taken from a complaint. The Trust are clear about how the learning will be used to improve services and support staff’
56. We then looked at whether the Trust carried out appropriate checks and examinations after Mr P’s fall and if there was a lasting impact of the fall.
57. Our nursing adviser confirmed there did not appear to be an injury because of the fall. The records suggest following the fall Mr P felt ‘light headed’ but had no head injury. We can see nursing staff helped him back into bed and it is documented he no longer felt light-headed and had no chest pains or palpitations and was feeling better.
58. The records show a doctor examined and advised nursing staff to monitor Mr P. In line with NICE guidance on falls and prevention, another risk assessment should have been completed which did not take place. We know Mr P did not fall again but this is still a failing.
59. Mrs Q also raised concerns about the Trust failing to contact her immediately after Mr P suffered his fall.
60. The Trust felt it was too late into the evening to contact Mrs Q and so it waited until the following morning.
61. Our nursing adviser explained once Mr P was made safe and had been assessed (seen by a doctor at around 10.15pm), the Trust should have contacted his family and informed them of the incident.
62. The decision is not in line CQC duty of candour regulations with care providers being open and transparent when an incident occurs.
63. We appreciate the distress and upset Mrs Q will have experienced because of not being informed of her son’s fall sooner.
64. The Trust has said staff involved in the incident at the time have been spoken to and the Trust has subsequently apologised to Mrs Q. Given there does not appear to be any lasting impact, we are satisfied the Trust has acted in line with NHS Complaint Standards and taken accountability and appropriate steps to learn from the experience.
65. Mrs Q raised further concerns about the Trust not catheterised Mr P when he became unresponsive on 2 September.
66. The Trust explained it reviewed Mr P and it noted his blood glucose levels were raised and novorapid (insulin medication) was administered, and Mr P was returned to the ward. It said catheterisation would not have been suitable. There were no concerns raised regarding Mr P’s urine output, which it stated was already minimal due to being on dialysis.
67. The records show Mr P became unresponsive whilst undergoing renal dialysis on 2 September 2023. Following this the Trust admitted him on to the renal in-patient ward.
68. Our renal nurse explained patients collapsing during renal dialysis is not uncommon and can occur due to intradialytic hypotension (an abrupt drop in blood pressure).
69. Our renal nurse told us there was no evidence to suggest the Trust should have catheterised Mr P. She explained had it done so this would have increased his risk of infection.
70. NHS guidance on ‘when urinary catheters are used’ states: ‘A urinary catheter is usually used when people have difficulty peeing (urinating) naturally.
71. Our renal nurse explained the Trust had Mr P on restricted fluids (1000mls per 24 hours) and he was nil by mouth, so there was no fluid intake to monitor and there appears to be no issue with him opening his bowels or urinating.
72. Our renal nurse went on to say catheter associated urinary tract infections (CA-UTIs) comprise a large proportion of healthcare as outlined in NICE guidance on infection prevention and control.
73. They explained that Mr P had a diagnosis of pancytopenia (This is a medical condition characterised by a low number of all three types of blood cells: red blood cells, white blood cells, and platelets. This can lead to symptoms like fatigue, increased infections, and bleeding, and its severity varies depending on the underlying cause).
74. Pancytopenia and urinary catheterisation are linked because patients with pancytopenia are more vulnerable to infections, and urinary catheters can introduce a risk for catheter-associated urinary tract infections, so this is a greater concern for a patient with pancytopenia. This is outlined in the NHS guidance on risks of urinary catheter.
75. Furthermore, urinary catheterisation is an invasive procedure that is not devoid of risk as it provides a direct route for infection. Our renal nurse explained best practice is to ensure the least invasive treatment is delivered to patients, especially in this case given Mr P had an extremely inflamed sore throat.
76. Considering Mr P’s diagnosis and symptoms we have found there was no clinical indication for urinary catheterisation. Had it been necessary to monitor Mr P’s fluid intake/output more stringently this would have been possible by measuring his output (using a bottle for passing urine into); a catheter was not required, and we are satisfied the Trust acted appropriately and in line with relevant guidance.
Conclusion
77. Weighing up the all the evidence, we found the Trust was correct not to catheterise Mr P when he became unresponsive given the added risks of infection. We are also satisfied the Trust has put things right in respect to Mr P’s unwitnessed fall, given there is no indication he suffered any injuries in respect this and given the Trust has taken steps to ensure this does not happen again in the future.
78. We have identified failings as the Trust did not carry another fall risk assessment after Mr P’s fall, however, we are satisfied this had no impact given Mr P thankfully did not fall again.
79. We have found the Trust should have contacted Mrs Q sooner following her son’s fall, but we are satisfied it has taken appropriate steps to put things right. As such, we have decided to not uphold the complaint against the Trust.
80. We understand and deeply empathise with Mrs Q's concerns in bringing this complaint to our office, particularly given the severity of her son's condition and subsequent tragic death. However, although, we acknowledge Mr P’s presenting symptoms were like those of a patient with Steven Johnson syndrome, we cannot say the medication prescribed by the Surgery or the Centre was inappropriate or not in line with guidance.