Decision Report 202102608

When it was originally published on 22 March 2023, this case referred to a Medical Practice in the Ayrshire and Arran NHS Board area. This was incorrect, and should have read a Medical Practice in the Fife NHS Board area. This was due to an administrative error which we have now corrected, and we apologise for any inconvenience that this has caused.

Summary

C complained about the end of life care their late spouse (A) had received from the practice. A had Lewy body dementia (a progressive dementia that results from protein deposits in nerve cells of the brain which affects movement, thinking skills, mood, memory, and behaviour) and was cared for at home by C. When A’s condition deteriorated, C complained that the GP had not visited them at home to assess their decline. C also complained that there had been a delay in initiating their end of life care plan allowing access to appropriate pain relieving medication and to the community palliative care team for support.

In response, the practice said that although a GP had not visited A at home in their final weeks, a number of GPs had been in constant liaison with the district nursing team about their care and prescribing appropriate medications. They noted that their duty doctor had not been aware of, or could refer into, the palliative care team but following liaison with the district nursing team, this was progressed and A had received assistance thereafter.

We took independent advice from a GP. We found that the practice had not provided a reasonable standard of end of life care to A. We considered they should have carried out an earlier assessment of A’s palliative and end of life needs to inform better care planning, that there was an unreasonable delay in providing A with appropriate pain relieving medication, and noted that staff lacked awareness of the community palliative care team and the referral process. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of end of life care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients experiencing a reported deterioration in their condition should be appropriately assessed in accordance with relevant national guidelines.
• Patients receiving end of life care should have their response to pain relieving medication appropriately assessed and any required changes promptly administered.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.