The Practice should have referred Mr A to a tissue viability specialist sooner
14. On 4 July 2024 Mr A came under the Practice’s care. Ms B told us she asked the Practice to refer Mr A to a tissue viability specialist in July for the multiple wounds he had on both legs causing serious pain. A tissue viability specialist is trained on the prevention, assessment and treatment of complex slow-healing wounds.
15. Mr A was seen by nurses from the Trust. The Trust reviewed Mr A on 5 and 6 July. No new concerns were noted over the condition of his legs. On 8 July, Mr A contacted the Trust complaining of a wet right leg. The Trust attended and Mr A told them the pain he experienced was usual for him.
16. On 9 July, Mr A told nurses he had been unable to sleep due to too much pain. The Trust referred Mr A to a tissue viability specialist on 10 July 2024.
17. NMC Code says nurses should make timely referrals to another practitioner when any action, care or treatment is required. TVN says a referral is necessary when there are difficulties controlling symptoms associated with the wound, for example wound pain.
18. When his pain worsened the nurses promptly referred Mr A to tissue viability team the following day, which was in line with TVN and NMC Code.
19. We consider the Trust acted in line with guidance when referring Mr A to tissue viability specialists at the point it was indicated. We have seen no signs anything went seriously wrong in this part of the complaint, so we will not be considering it further.
The Practice should have referred Mr A to a dermatologist sooner
20. Ms B told us on 14 October she contacted the Practice to tell them Mr A had a rash on his hands. She asked for a referral to a dermatologist, but the Practice refused. Dermatologists are trained to diagnose and treat conditions affecting the skin.
21. The Practice records show on 14 October, Mr A called the ambulance services due to concern over the rash. The paramedic called the Practice to explain they suspected the rash was eczema.
22. The Practice contacted Mr A to discuss his symptoms. In this call, the Practice suggested Mr A could be prescribed antihistamines. Mr A refused and said he was allergic.
23. The Practice then contacted Mr A by text message asking for him to send pictures of the rash. Mr A sent these pictures on 14 October. The Practice prescribed a steroid cream.
24. Ms B says on 16 October she asked the Practice to refer Mr A to a dermatologist again, but the Practice refused. The Practice records state it told Ms B, Mr A should try the steroid cream it had prescribed before it refers him to a dermatologist.
25. On 17 October the Trust visited Mr A and asked the Practice to make a dermatology referral. The Practice did this on 23 October. Ms B’s notes show on 13 November a dermatologist visited Mr A.
26. NICE guidance on eczema says when a patient presents with symptoms of eczema, the Practice should first consider offering treatments including topical steroids, and a one-month trial of antihistamines. If unsuccessful, the patient should be referred to a dermatologist.
27. We can see the Practice tried Mr A with a steroid cream and suggested antihistamines before it referred him to dermatology in line with NICE guidance on eczema. When Mr A and the Trust reported that was not working, the Practice referred him to dermatology. This was nine days after his first presentation of symptoms.
28. We are satisfied the Practice acted in line with guidance and the referral was made at an appropriate point. We can see no signs anything went seriously wrong in this part of the complaint, so we will not be considering it further.
The Practice did not refer Mr A to the correct specialists
29. Ms B told us she wanted the Practice to help get to the root cause of Mr A’s problem. Ms B told us she thought the Practice could have referred Mr A to other specialists.
30. We considered if the Practice referred Mr A to relevant specialists. Mr A was under the care of a vascular team from the beginning of his care at the Practice. Vascular is a team specialising in diseases of the arteries and veins. He remained under the care of vascular throughout his time at the Practice.
31. Mr A was referred to: • district nurses for a leg ulcer/chronic oedema assessment on 9 July 2024 • the tissue viability service on 10 July 2024 • community podiatry on 18 July 2024 • dermatology on 23 October in response to a rash.
32. NMC code says nurses should respect the skills, expertise and contributions of their colleagues’ referring matters to them when appropriate.
33. Practice records show the Trust Referred Mr A to the tissue viability specialists, the podiatrist and the GP when needed. Our adviser confirmed these referrals were in keeping with what they would expect to see given Mr A’s symptoms. They did not identify any instances where the Trust should have made referrals that they did not make.
34. Considering Mr A’s presenting condition, the records and our nurse adviser’s advice, we are satisfied the nurses acted in line with the NMC code. We have seen no indications of failings in the Trust’s actions in relation to this part of the complaint.
35. GMC guidance on practice says Practice’s should refer a patient to another suitably qualified practitioner when this serves their needs. Our GP adviser agreed Mr A should have been under the care of a local vascular team, and other referrals were in keeping with what they would expect to see given the poor circulation in his foot, his rash and his persistent leg wounds.
36. We are satisfied the Practice has followed GMC guidance on practice to promptly provide suitable advice and investigation when necessary. For the reasons outlined above, we can find no indications of failings by the Practice or the Trust.
The Practice did not supply and adequate amount of Mepilex dressings
37. Ms B told us the only dressings Mr A was not allergic too were Mepilex dressings. Mepilex dressings are foam dressings used to treat serious wounds. They are known for causing minimal pain and skin damage during removal. Mr A needed Mepilex dressings to promote healing in his legs. Ms B complains the Practice did not supply enough dressings for Mr A’s legs.
38. Ms B told us Mr A needed seven dressings on each leg every day, a total of 14 per day. She told us the Practice ordered Mepilex in packs of 80. This meant Mr A ran out of dressings on the weekends and was left in pain.
39. Ms B told us she called the Practice and asked them to increase the number of dressings to 100 and it refused. Ms B told us the Practice were annoyed about the price of Mr A’s dressings so refused him the treatment.
40. We have conducted an in-depth review of the prescription records. We can see the Practice increased Mr A’s prescription on 14 October. We can see the Practice gave Mr A extra dressings when he ran out on 23 October and it increased Mr A’s prescription to eight Mepilex a day on 1 November. Mr A was also prescribed an extra 100 Mepilex on 8 November and 15 November.
41. We can also see Mr A was dressing his own legs against the Trust’s advice. On 1 November the Trust informed the Practice Mr A was re-dressing his own legs which then caused him to run out of dressings. The Trust told the Practice Mr A needed two dressings a day. This was noted again by the Trust in Mr A’s records on 16 November.
42. We can see the Practice made notes on its conversations with Ms B. On 9 October, the Practice said it told Mr A if he wanted any further dressings, he would have to fund this himself. On 6 November the Practice noted the 96 dressings Mr A requested would cost £464 a week and £1,856 a month. It is our view it is likely the Practice communicated their concerns about the cost of Mr A’s dressings to him and Ms B.
43. NICE guidance on Mepilex says dressings should be changed every three days but may need to be changed sooner depending on the wound’s fluid level.
44. GMC guidance on prescribing says when patients ask for treatment that is not in their clinical interests, doctors should explore the reasons for their request, their expectations, and desired outcome. If the treatment would not serve the patient’s needs, the practitioner should not propose it.
45. Additionally, GMC guidance on practice says Practice’s must make good use of the resources available to them, taking into account their responsibility of care to the wider population.
46. We have considered whether what happened was in line with guidance.
47. Although Mr A’s prescription changed often, on average Mr A was prescribed eight dressings per day. This is substantially higher than the recommended amount in NICE guidance on Mepilex. We can see the Practice increased the number of Mr A’s dressings when it could see this was in his clinical interests. This is in line with GMC guidance on practice.
48. It is our view any concerns the Practice may have had over the price of dressings was reasonable, and in line with GMC guidance on practice. We can see this did not compromise its duty of care, as Mr A was prescribed the correct number of dressings for his needs.
49. We have not seen any signs anything went seriously wrong in this part of the complaint, so we will not be considering it further.
The Practice did not have an adequate plan in place for Mr A’s care
50. Ms B told us when Mr A was transferred to the Practice’s care, the Practice and Trust did not put a clear plan in place to help improve Mr A’s clinical condition. Ms B explained this added to their feelings of hopelessness.
51. We have considered the Practice and Trust records. On 9 July, we can see a doctor from the Practice visited Mr A at home and discussed his history.
52. It noted Mr A was having care input from the vascular team. It also discussed Mr A’s pain relief. The Practice records state Mr A was happy with the plan discussed for his care.
53. The Trust planned to visit Mr A at his home address once a day. On 15 July, this changed to twice a day.
54. On 13 September, the Trust decreased its visits to three times a week. On 9 October the Trust increased its visits to once a day. Ms B told us this was usually in the afternoon. Ms B told us she also felt this was inadequate because Mr A needed his dressings changed sooner than this. Ms B’s notes state there were three instances where Ms B was unhappy with the time nurses arrived and they dressed Mr A’s legs.
55. On 7 November the Practice records listed the goals for Mr A’s care. At this time Ms B also made a record a treatment plan was being put in place following input from the vascular team and dermatologist.
56. GMC guidance on practice says Practices should arrange treatment where necessary and consult colleagues where appropriate.
57. Our GP adviser explained the Practice should have communicated with the nurses treating Mr A to understand his treatment needs.
58. RCN guidance says nurses should have used the evidence in front of them with their professional and clinical judgement to assess, plan and implement person-centred nursing care.
59. Our nursing adviser explained the Trust used its clinical judgement to plan for Mr A’s nursing care and communicated this to the Practice. We consider this was in keeping with RCN guidance. We consider it is not always practical for nurses to visit at the same time each day. We consider three late visits from the Trust is not sufficient to amount to a failing in the care it provided.
60. We can see the Practice followed GMC guidance in listening to the Trust’s nurses and expertise on Mr A’s condition. As addressed above, we can see the Practice referred Mr A to appropriate specialists to plan for his care.
61. We appreciate Ms B feels a clear plan was not communicated to Mr A and we understand it was difficult time for them. We can see evidence in the records show a plan was discussed with Mr A on 9 July and 7 November. We consider this communication was appropriate.
62. Overall, we are satisfied there are signs anything went seriously wrong in this part of the complaint, so we will not be considering it further
The Practice failed to increase Mr A’s pain relief when his pain levels increased
63. Ms B told us Mr A’s pain relief was not strong enough and only worked for about two hours. Ms B says this meant Mr A was in more pain than necessary.
64. We reviewed the Practice records of Mr A’s pain relief prescription. When Mr A came under the care of the Practice, he was prescribed 30mg slow-release oxycodone tablets every twelve hours. Oxycodone is a type of morphine, prescribed for pain relief.
65. On 9 July, following a home visit, the Trust asked the Practice for a medication review. The Practice prescribed additional oxycodone solution for breakthrough pain. Breakthrough pain is a sudden flare-up of intense pain that is more than the patient’s standard level of chronic pain. The prescription was for 5mg to be taken as needed every four hours.
66. On 14 and 23 July the Trust asked the Practice for further reviews and the Practice increased Mr A’s regular prescription of slow-release tablets to 40mg then to 60mg, every 12 hours. Mr A remained in severe pain throughout August, and the Practice prescribed additional breakthrough solution.
67. In early September Mr A was admitted to Hospital. Whilst an inpatient this Hospital reduced Mr A’s 12 hourly medication back to 30mg (this reduction is outside of the scope of this consideration). On the day of discharge Mr A asked the Practice for additional breakthrough solution to manage his pain and the Practice increased his prescription to 7.5mg as needed up to four hourly.
68. Mr A’s pain continued to cause him significant distress, and this was noted in the nursing records. Ms B noted Mr A was in severe pain on 9 and 19 October. The Practice prescribed breakthrough solution as requested. On 18 November Ms B told the Practice his pain was intolerable, shortly after he was admitted to hospital.
69. NMC code says the Trust should make a timely referral to another practitioner when care or treatment is required. We can see the Trust acted in line with NMC code on 9 July and 14 July when they contacted the Practice to report Mr A’s change in pain level.
70. GMC guidance on prescribing says a Practice should prescribe medication when it has adequate knowledge of the patient’s health and are satisfied it will serve their needs. It says a patient’s pain relief should be increased when they have a sustained marked increase in pain.
71. NICE guidance on pain says patients should be offered rescue doses if they experience breakthrough pain. Breakthrough pain relief should be between one sixth to one tenth of the standard daily dosage to be taken when required and repeated no more than six times in 24 hours.
72. We can see the Practice followed GMC guidance on prescribing on 14 and 23 July when it recognised Mr A had an increase in pain levels, and more medication would serve his needs. A day of severe pain as Mr A had on 9 and 19 October was not a sustained increase in pain. The Practice’s decision to not increase Mr A’s prescription on these occasions was in line with GMC guidance on prescribing. Our GP adviser told us Mr A’s breakthrough pain relief was always kept at the recommended dosage specified in NICE guidance on pain.
73. We can see Mr A had severely infected and ulcerated legs. We do not doubt this would have been extremely painful. Our GP adviser explained given Mr A’s symptoms, it is unlikely he would have ever been pain free.
74. Overall, we can see the Practice and the Trust followed appropriate guidance and we can see no signs anything went seriously wrong in this part of the complaint, so we will not be considering it further
The Practice prescribed Mr A antibiotics and steroid cream he was allergic to
75. Ms B told us Mr A had lots of allergies and the Practice incorrectly prescribed antibiotics and steroid cream to Mr A that he was allergies too, causing avoidable pain.
Antibiotics
76. On 24 October, Mr A was prescribed an antibiotic named erythromycin. On 27 October, the Trust attended to Mr A who said he had reacted to erythromycin. The Trust noticed a rash on Mr A and told him to stop taking erythromycin. This same account is documented in Ms B’s record.
77. On 28 October, the Practice viewed the Trust’s report. The Practice recorded erythromycin as a drug sensitivity on Mr A’s medical records.
78. BNF guidance says a non-immediate reaction can be localised inflamed skin usually onset three days after second exposure. The Practice should consider telling the patient to stop the medication. It also says the suspected drug allergy should be clearly and accurately documented in clinical notes.
79. We can see when Mr A presented with a rash on 27 October, he was told to stop taking erythromycin and given a replacement. The Practice then recorded a drug sensitivity. We can see the Practice acted in line with BNF guidance.
80. On 6 November, Mr A was prescribed erythromycin for a second time. Ms B’s notes say she went to pick the antibiotic up from the pharmacy and noticed it was the wrong one. Ms B went to pick up a replacement antibiotic on 7 November.
81. GMC guidance on prescribing says practitioners should prescribe drugs only when they have adequate knowledge of the patient’s history including any adverse reactions to drugs.
82. The Practice did not follow GMC guidance on prescribing on 6 November when it prescribed a drug Mr A was allergic to. The Practice should have used its knowledge of Mr A’s history before prescribing erythromycin. This was not in line with guidance.
83. We then considered the impact of this failing. We can see Mr A did not take the antibiotic, meaning no discomfort or pain was caused. The Practice prescribed Mr A replacement the day following, meaning this was quickly resolved.
84. We recognise there was a failing in the antibiotic prescription on 7 November, but we cannot link this to the claimed impact of avoidable pain. For this reason, we consider there is no unremedied injustice.
Steroid cream
85. On 23 August, Mr A was prescribed the steroid cream betamethasone valerate. We looked at the Practice notes from the period of care after this date. We found no signs of any reported reactions. Ms B’s notes also state on 29 August, the cream Mr A was using was improving his rash.
86. On 14 November, we can see the Practice prescribed Mr A the steroid cream Audavate. On 19 November, Ms B’s notes say Mr A had a reaction. We cannot see this was reported to the Trust or the Practice.
87. We cannot see any evidence of this reaction in the Practice records. Mr A was admitted to hospital two days after on 21 November due to concerns over an infection on his legs.
88. GMC guidance on prescribing says practitioners should prescribe drugs only when they have adequate history of the patient’s health. The Practice should have considered Mr A’s health and existing allergies before prescribing any cream.
89. Our GP adviser reviewed the medical records. We can see the records show Mr A had used Dovobet in 2008 and had no reaction. Our adviser confirmed Betamethasone Valerate has the same ingredient in as Dobovet. They also confirmed based on the records, Audavate contained no ingredients that Mr A was known to be allergic to.
90. Considering the guidance and Mr A’s records we are satisfied the Practice adequately considered Mr A’s health before prescribing the steroid cream by looking at his health history. This is in line with GMC guidance.
91. We were sorry to hear of Mr A’s reaction. We can see no signs anything went seriously wrong in this part of the complaint, so we will not be considering it further.
The Practice unjustly removed Mr A from the Practice and notified him by letter home
92. Ms B complains Mr A was removed from the Practice unjustly and notified by a letter to his home when he was a hospital inpatient. Ms B told us trying to find a new Practice was extremely stressful.
93. The Practice records show on 16 October the Trust visited Mr A at home. The records state Mr A told the Trust he was unhappy with the Practice and used verbal abuse about the Practice throughout the visit.
94. The same day, the Practice wrote a letter to Mr A. It explained Mr A could make a formal complaint if he was unhappy and warned him any further incidents of verbal abuse would result in removal from the Practice.
95. On 1 November, the Trust visited Mr A at home. Records say Mr A was grabbing dressings and being rude to the nurses. The Trust called Mr A and Ms B after this visit. It told Mr A that the nurses were upset at the shouting and swearing from Mr A that day.
96. Ms B told the Trust Mr A had shouted in pain and frustration. The Trust explained they understood but it was not acceptable to be shouting and swearing. The Trust warned this could not happen again.
97. On 1 November, the Practice completed a violence and abuse risk assessment. It stated Mr A had become verbally abusive and swore at two members from the Trust.
98. On 20 November, the Trust visited Mr A at home. The records state Mr A began shouting in pain and hyperventilating. Mr A became agitated, threatened to end his life and had a panic attack. Mr A raised his voice but apologised after calming down. This was reported to the Practice manager.
99. Ms B told us when Mr A was screaming in agony, he did not direct any abusive words toward the nurses, and he was swearing in pain. Ms B told us Mr A apologised straight after.
100. On 22 November, Mr A received a letter from the Practice stating he was being removed as a patient. The Practice stated the reasons for removal were inappropriate behaviour, verbal abuse and offensive comments about a doctor at the Practice.
101. PRP guidance says if a patient is to be removed from the Practice, there must be legitimate grounds. Legitimate grounds include violence or threatening behaviour. It says it has zero tolerance to any abuse directed at a member of staff and if violent or abusive behaviour occurs, the Practice should issue a warning and record this on record.
102. BMA guidance says Practices have the right to remove patients when there is violent or abusive behaviour. It says the Practice should first issue a written warning giving the reasons for possible removal. BMA says patients must be given eight days to find a new Practice.
103. We can see Ms B did not perceive Mr A’s behaviour as threatening. We can see the Trust did find it threatening, and we cannot undermine the feelings of the nurses or their experience.
104. The Practice gave Mr A a written warning before removing him. This follows PRP and BMA guidance. We can also see an extra verbal warning was given on 1 November beyond PRP and BMA guidance. We consider this was empathetic to the pain Mr A was in, and it was appropriate to give him another opportunity to stop his behaviour.
105. We appreciate it would have been distressing to receive the removal letter while Mr A was an inpatient in hospital. We can see Mr A was warned this would happen if his behaviour continued. For this reason, we consider the Practice’s actions were appropriate and in line with guidance. We can see no signs anything went seriously wrong in this part of the complaint, so we will not be considering it further.
The Practice did not conduct a fair investigation into Ms B’s complaint
106. Ms B told us she is unhappy with the Practice’s investigation of her complaint. Ms B addressed her complaint to a specific doctor at the Practice. Ms B says the Practice manager investigated her complaint instead.
107. Ms B says the Practice manager did not have an independent view as they were personally mentioned in the complaint for sending upsetting letters to Mr A. Ms B says the complaint response had no care or compassion.
108. We have considered the Practice’s complaint response. The Practice offered condolences for Mr A’s loss. The Practice said it considered the medical records and all correspondence available to them. However, the Practice makes no reference to dates, specific entries in the medical records or names of guidance it followed.
109. The Practice did not use the ‘what happened’ compared to ‘what should have happened’ structure. The Practice did not uphold Ms B’s complaint as it could find no failings.
110. The Practice complaint policy says the practice manager will act as the complaints manager and investigate all complaints. PHSO guidance says complaint handlers should not be involved in the complaint, but where this is unavoidable, they should demonstrate how they are acting fairly.
111. PHSO guidance states complaint handlers should compare what happened to what should have happened using appropriate guidelines and standards.
112. According to the Practice’s complaint policy, the practice manager was the correct person to investigate Ms B’s concerns. This does not go against any PHSO guidance.
113. Ms B says the complaint response had no care and compassion. We recognise there was an opportunity for the Practice to be more empathetic in its response, however we cannot conclude there was no empathy or compassion at all.
114. We are not satisfied the practice manager demonstrated how they acted fairly in their investigation. This is because there is no comparison of what happened to what should have happened, and no guidelines were used.
115. Although the complaint response did not meet PHSO guidance, we can see our investigation has come to the same conclusion as the Practice’s investigation. For this reason, we cannot conclude Ms B’s complaint was handled unfairly. Although we can see the complaint response could be of a better standard, there is no indications of a failing.
Conclusion
116. We recognise Mr A went through an extremely distressing and difficult time. We were extremely sorry to hear of Mr A’s death during our complaint process. We hope our independent review and scrutiny reassures Ms B the care Mr A received was of the correct clinical standard.