Follow-up care
24. Mrs A says when Miss X completed alcohol addiction rehabilitation on 28 February 2024 the Practice did not arrange ongoing mental health or addiction support in the community.
25. We can see from Miss X’s medical record the Practice did not offer any community support for alcohol addiction following completion of her alcohol detox program. We have considered the NICE guidelines referenced in our ‘Evidence’ section and the advice from our Adviser.
26. We can see that a number of different services were involved in providing support to Miss X, and each service has a responsibility to provide a particular function. We understand from our Adviser that providing community support for alcohol addiction would not normally fall within the responsibilities of a GP. This would normally be provided by a specialist alcohol rehabilitation service, which our evidence shows was in place in February 2024.
27. We do note that GPs and other primary care services can provide support with mental health, and this would usually begin if the patient raises concerns or asks for help, and if they consent to receiving that help.
28. We can see from the available evidence Miss X was under the care of an alcohol rehabilitation service until 24 April 2024. The service discharged her after she experienced a relapse and did not engage consistently with the support offered.
29. Miss X’s medical records show, following completion of her alcohol detox programme, she had several contacts with the Practice and the OOH service, mainly concerning physical health issues. Miss X also had contact with the mental health crisis resolution team (the crisis team) from her local NHS trust when there were concerns about her mental health. The crisis team contacted Miss X on 24 March 2024 and, following their assessment, decided no further action was required at that time.
30. On 2 May 2024, a paramedic assessed her at home and advised admission to an accident and emergency department (A&E) and a referral to the crisis team, but Miss X declined. She was later reviewed at home by the joint emergency team (JET) on 4 July 2024, who advised attending hospital, but she also declined this recommendation.
31. We can see from the available evidence on 6 July 2024 the police control room referred Miss X to the crisis team after she had expressed suicidal thoughts whilst under the influence of alcohol, but the team could not contact Miss X for an assessment.
32. We understand from our Adviser that in Miss X’s case, involvement from other agencies, such as mental health services, adult social care, and safeguarding would normally be expected. Her medical records show that such collaborative involvement did occur. On 6 August 2024, a multi-disciplinary team (MDT) meeting took place, which involved adult social services and the safeguarding team.
33. We understand from our Adviser, given that support for Miss X’s addiction and mental health was already being offered by the relevant services that specialised in support for those matters, there was no further action to be provided from the GP in their role to provide care in the community. We also note that during this time we cannot see anything to indicate that Miss X requested further support for her mental health from the Practice. It appears that due to Miss X not engaging with the Practice and other services, and as they could not compel her to do so, she unfortunately did not receive the continuity of care that her family was hoping for.
34. In view of the above, we cannot see any indications the Practice failed to act in line with applicable standards in providing Miss X with GP support for her mental health or alcohol addiction when she completed alcohol detox in February 2024. We can see from the NICE guidance and GMC guidance referred to in our ‘Evidence’ section, the decision to refer a patient to specialist mental health services is a matter of clinical judgement, taking into account the patient’s presentation, need for consent, level of risk, and whether their needs can reasonably be managed within primary care. The evidence available shows the Practice considered those factors and the input of the other services already involved in Miss X’s care.
35. Miss X was treated by a specialist service for her alcohol addiction but sadly relapsed, and for both her addiction and mental health needs she did not agree to the support offered or recommendations made by the Practice and specialist organisations that were involved in her care. We understand from our Adviser the GP’s role in this context was to provide primary care support, and they are unable to provide emergency or specialist care in the way we can see the family was hoping.
36. We are very sorry to hear about Miss X’s experience and recognise that the multiple health needs, including mental health and alcohol dependency, alongside interacting with a range of services, must have been a very difficult and complex situation for Miss X and her family.
Blood test results
37. Mrs A says Miss X’s blood test results in October 2024 showed a decline in her liver function. The Practice was unable to contact Miss X regarding this, and she refused to attend an appointment for a review. Mrs A questions why, given Miss X’s mental health history, the Practice did not take any further action to ensure she was followed up about her liver function.
38. We can see from Miss X’s medical records that on 25 October 2024 a clinician at the Practice reviewed her blood test results. On 28 October 2024, the Practice sent her a letter inviting her to attend a health review appointment. On 7 November 2024, a clinician attempted to contact Miss X by telephone to discuss her blood test results, but there was no answer. The Practice sent her a message explaining the reason for the call and informing her that another attempt would be made the following day. A further attempt to contact her the next day was unsuccessful.
39. The clinician noted in the record on 8 November 2024 that the blood test results were abnormal but slightly better than the previous year’s results. An urgent request to a GP within the Practice to arrange a home visit for Miss X on 11 November 2024 was made. The Practice contacted her successfully on that date to arrange the visit. However, we can see from the medical notes, Miss X declined the home visit and instead agreed to attend a face-to-face appointment at the Practice on 12 November 2024.
40. On 12 November 2024 Miss X called the Practice to cancel her appointment. During that call, a GP advised her that, due to the symptoms she said she was experiencing, she should attend A&E. Miss X agreed to do so and was given safety netting advice (guidance on what to do if her symptoms changed or worsened), in line with GMC guidance.
41. We can see from the available evidence the Practice took further action to follow up the blood test results and made multiple attempts to assess Miss X. We understand from our Adviser that if a patient declines assessment or treatment, there are limits to what a GP can provide, and there is nothing to suggest the Practice should have taken further or different steps at that time. In view of the reasons above, there is no indication the Practice failed to take appropriate steps regarding the abnormal blood test results.
Capacity and consent to treatment
42. Mrs A questions why, given her long history of poor mental health and alcohol abuse, the Practice considered Miss X to have the capacity to make decisions about her care.
43. We can see from the NHS.uk guidance on capacity referred to in our ‘Evidence’ section above that ‘capacity means the ability to use and understand information to make a decision, and communicate any decision made’.
44. We understand from our Adviser capacity can vary from time to time, particularly if there are other factors involved, such as being under the influence of alcohol. We can see from Miss X’s medical record, at the times her capacity was recorded by the Practice and by various clinicians from other organisations who reviewed her, they documented she had capacity.
45. We understand from the NHS.uk guidance on capacity and from our Adviser that capacity is also decision specific. A person’s capacity to consent can change. For example, they may have the capacity to make some decisions but not others, or their capacity may come and go. In some cases, people can be considered capable of deciding some aspects of their treatment but not others.
46. The MCA says ‘A person is unable to make a decision for himself if he is unable:
• (a) to understand the information relevant to the decision, • (b) to retain that information, • (c) to use or weigh that information as part of the process of making the decision, or • (d) to communicate his decision (whether by talking, using sign language or any other means)’.
47. We understand from our Adviser, the MCA and NHS.uk guidance that when deciding if a person has capacity, it should be taken they do, even with a history of mental health or alcohol abuse, unless they meet any of the criteria above listed in the MCA. From the available evidence, we cannot see anything to suggest Miss X met the MCA criteria for lacking capacity when her capacity was assessed.
48. In view of the above, we cannot see any indication the Practice failed to act in line with the MCA guidance when deciding whether Miss X had capacity, even though she had long-term mental health problems and alcohol dependence.
49. We recognise how situations involving capacity, mental health and alcohol misuse can be complex and unclear. We can understand how these circumstances would have been deeply distressing for Miss X’s family members, particularly where her needs and how she presented to clinical staff may have differed from how her family saw them.
50. We know Mrs A and other family members will have seen Miss X during periods when she was very ill and they were clearly very worried and looking for any way they might be able to help her, so we do understand why they feel so strongly that any clinician who saw Miss X should have done more. We hope this goes some way to explaining why we have not seen evidence to show the Practice could and should have taken different steps here.
Referral requests
51. Mrs A says during 2024 the Practice received multiple requests from other organisations for Miss X to have a mental health or adult safeguarding referral, but the Practice did not act on these. Mrs A also says the Practice did not refer Miss X to an Advanced Mental Health Practitioner for an urgent mental health assessment after requests were made by family members on 22 November 2024.
52. We can see from the available evidence that when contact was made Miss X had mental health assessments by the crisis team with symptoms such as low mood and suicidal thoughts. She was referred by various organisations, including the OOH primary care service, ambulance service and police service. Miss X also referred herself to the crisis team on 19 October 2024. We can see Miss X was known to the hospital liaison psychiatry team and dual diagnosis outreach team. This is a community mental health team that supports people who have both a mental health condition and a substance misuse disorder.
53. Miss X’s needs were discussed at an MDT meeting on 6 August 2024, and she was referred to a Multi-Agency Safeguarding Hub (MASH). A MASH is a local authority–led team where different agencies share information quickly to decide whether a vulnerable adult is at risk and what action is needed. We can see from the medical notes, as an outcome of this referral, Miss X was referred for reablement. Reablement is a short-term social care service which provides support such as help at home with daily living tasks. A letter explaining this outcome was sent to Miss X on 3 September 2024, along with an invite to an appointment for a review.
54. We can see from the available evidence, adult social services sent a routine email to the Practice on 30 October 2024 after they had visited Miss X. The social worker emailed the Practice requesting a referral for Miss X to a mental health service and a review for medical symptoms she was experiencing. On 8 November 2024 a clinician from the Practice attempted to contact Miss X regarding this request from the social worker but was unable to speak to her. Miss X was added to the GP home visiting list, and the clinician documented the need for consent from Miss X to refer her again to the mental health service. Unfortunately, this face-to-face review did not take place as Miss X cancelled the home visit and declined a review.
55. We understand from our Adviser that the necessary agencies a GP would normally refer to for supporting patients with health issues like Miss X were already involved in her care. Miss X was known to the relevant mental health teams and was under the care of the adult social services and safeguarding teams. This means the Practice could only have contacted organisations who were already supporting Miss X, and it did take the steps it could to try to re-refer her to mental health services. It also depended on Miss X providing consent to any referral.
56. We can see from the available evidence that Miss X was sadly not engaging with the various organisations that were offering support. In view of this, we cannot see any indication the Practice failed to ensure Miss X was referred to the relevant agencies for the period up to 18 November 2024.
57. On 18 November 2024 the social worker emailed the Practice again regarding the request for Miss X to be referred to a primary mental health service for an assessment. On 20 November 2024 Mrs A and another family member emailed the Practice raising urgent concerns about Miss X’s mental and physical wellbeing and her capacity to make decisions about her care. They requested a section 12 urgent mental health assessment. This is an assessment carried out under the Mental Health Act 1983 (the Act) in England and Wales by an Advanced Mental Health Practitioner who is specially approved under Section 12(2) of the Act. The Practitioner will assess whether someone needs to be detained in hospital for their own safety or the safety of others. This can only be done under the legal framework of the Act as depriving a person of their liberty is one of the most serious actions taken in healthcare and this decision must be made with great care.
58. On 21 November 2024 a rehabilitation service worker from another organisation emailed the Practice to support the requests made by Miss X’s family members for an urgent assessment. On the same day an adult safeguarding team member emailed the Practice to raise urgent safeguarding concerns about Miss X and requested an urgent mental health assessment to be carried out for Miss X.
59. We cannot see any evidence from Miss X’s medical record that these emails were reviewed by the Practice until 22 November 2024.
60. We can see from the available evidence, on 22 November 2024 Miss X was medically unwell and required an emergency ambulance, but she refused an assessment by the ambulance crew. The crew recorded Miss X had ‘full capacity’ at the time. We can see on the same day Mrs A spoke to a GP at the Practice regarding her concerns. The GP advised if Miss X was refusing to attend A&E, a mental capacity assessment could be carried out with regards to sectioning Miss X to take her to hospital. We cannot see evidence of any further contact on this day.
61. Sadly, we can see from her medical record, Miss X deteriorated the next day and was admitted to hospital. Miss X was treated in hospital and very sadly died on 25 November 2024 from a severe abdominal infection caused by a spontaneous perforation in the bowel. This occurred as a complication of advanced alcohol-related liver disease.
62. We understand from our Adviser, according to the GMC guidance referred to in our ‘Evidence’ section, the Practice should have reviewed and responded to the concerns raised between 18 November 2024 and 22 November 2024, ideally on the same day as these were marked as urgent requests. In view of this, we can see this is an indication of a communication failing by the Practice.
63. Mrs A says the failings prevented Miss X from being sectioned under the Act and hospitalised. She says because of this, Miss X was unable to receive medical treatment sooner, which caused her death. We have very carefully considered whether there is any indication the delay of up to four days by the Practice in acting on the referral requests meant Miss X was unable to receive medical treatment.
64. Having considered all the evidence available to us, including input from our Adviser, we cannot say on the balance of probability that any delay by the Practice in reviewing the referral requests led to the very sad outcome for Miss X. This is because there were many influencing factors and organisations involved in her care.
65. If the Practice had acted on the referral request at the earliest opportunity, we understand it would have needed to contact the mental health crisis team. We cannot give any view as to whether the mental health crisis team would have accepted the referral, any timeframes in which it would have actioned an assessment, what the outcome of an urgent mental assessment would have been, and whether Miss X would have been sectioned or not. This is because the assessment would have been specific to the time it was performed, and a decision to section would be dependent on the assessment made by the Advanced Mental Health Practitioner. As noted previously, Miss X was generally noted to have capacity, despite her illness, and so it is possible that she would have been found to have capacity to refuse treatment at the point any assessment was carried out. To say more than this would be speculation on our part.
66. Mrs A tells us that a swifter response by the Practice may have led to quicker medical support for her sister. We can see from the available evidence Miss X suffered a complication of her chronic alcohol-liver disease. We understand from our Adviser that we also cannot say on the balance of probability that if Miss X had been sectioned and received hospital treatment sooner that she would have had a different clinical outcome, as this was a long-term condition and by the time of the referral requests to the Practice she was clearly already very unwell medically. In view of this, we have not seen anything to indicate the delay in communication regarding a mental health referral led to Miss X’s sad death, and so we will take no further action.
67. We can see that the delay clearly caused Mrs A and her family some frustration and distress, and the Practice has recognised that a delay did occur. It apologised for this and explained it would review its processes to improve them in future. Having considered our Principles for Remedy, which say organisations should ‘compensate people appropriately’ and ‘learn from complaints’, we are glad to see it has taken these steps and so taken the action available to it at that time to put things right.
68. We recognise this experience must have been upsetting for Miss X, and her death, under the circumstances, must have been very distressing for her sister Mrs A and other family members. I hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it, and we hope our independent view is reassuring to Mrs A. We would like to thank Mrs A for bringing her concerns to our attention.