Decision Report 201203832

Summary

Mr C complained about the care and treatment that his wife (Mrs C) received from her medical practice before her death. Mrs C had a number of falls and twice fell down the stairs at home. This resulted in an ulcer on her leg and a large boil-like growth on her elbow. Mr C complained that although the practice treated Mrs C's elbow, they did nothing about the ulcer on her leg, which deteriorated.

We took independent advice from our GP medical adviser who said that although GPs do not treat leg ulcers, they should refer a patient to nurses or a service to administer dressings and compression bandages where appropriate. We found that the practice had appropriately referred Mrs C to the practice nurse and the district nursing service for treatment for her ulcers. We also found that it was reasonable that the practice did not initially consider the wound on Mrs C's leg to be an issue and did not consider that it required treatment until they reviewed it a few weeks later. We took the view that Mrs C's ulcers were appropriately treated.

Mr C also complained that the practice did not ensure that Mrs C was admitted to hospital when her condition deteriorated. The notes made by both the district nurses and the practice showed that Mrs C did not want to go into hospital at first. However, her condition deteriorated and the next day, she confirmed that she was now willing to go there. The practice then contacted two hospitals to try to arrange admission. We found that the delay in arranging this was not due to the practice's failure to respond, but due to problems in getting the hospitals to accept Mrs C as an in-patient, and that the actions of the practice had been reasonable and appropriate. Although we did not uphold Mr C's complaints, during our investigation we identified that the district nurses, who were employed by the local health board, had not given the practice all the relevant details about the deterioration in Mrs C's condition and so we made a recommendation about this.

Recommendations

We recommended that :

• hold a joint significant event analysis discussion with the district nurses in order to reflect and learn from this case.