Decision report 201003593

Summary
Mrs C complained about the care and treatment provided to her late mother, Mrs A, by her medical practice. While under the care of the practice Mrs A received treatment for leg ulcers and symptoms relating to her underlying vascular condition. Mrs C complained that over a two month period the practice failed to refer Mrs A to hospital within a reasonable time, which meant that her vascular condition was not investigated until she was admitted to hospital. Mrs C also complained that after Mrs A was discharged from hospital the practice failed to refer her back there when the condition of her left heel deteriorated and she experienced continued leg pain. Mrs C also said that the practice failed to refer Mrs A to social work for home care assistance despite the fact that she lived alone and was incapable of self caring. Our investigation found that the delay in referring Mrs A to hospital was not reasonable, and we upheld this complaint as well as the complaint about referral to social work. However, we found that the standard of care Mrs A received from the practice after she was discharged from hospital was acceptable, as during that time she was also seen as a hospital out-patient.

Recommendations
We recommend that the medical practice:
• review the management of patients with peripheral vascular disease, seeking advice from hospital colleagues where appropriate;
• review their procedures for liaison with district nurse staff, particularly where concerns are raised by them;
• review their procedures for referral to social work;
• conduct a significant event audit into the clinical management of Mrs A and ensure lessons are learned; and
• apologise to Mrs C for the failures identified.