Summary
After suffering a stroke earlier in the year, Mr A was discharged from a hospital to a Step Down Unit in May 2014. This is a unit in a nursing home for elderly patients who are fit for discharge from hospital but need further rehabilitation before they can return home. Following a fall at the unit in early July 2014, Mr A's condition deteriorated. Over a number of weeks, he developed reduced mobility, reduced food intake and increasing pain. Mr A's daughter (Miss C) complained that, from the time of his fall until his readmission to hospital in early August, the care and treatment he received from GPs at his medical practice was unreasonable. She considered that Mr A should have been admitted to hospital earlier, and that it was unreasonable for a GP to suggest that one of the options was not to intervene, but to keep Mr A comfortable in the unit.
I took independent advice from one of my medical advisers who is a GP. The adviser had a number of concerns about the practice's failure to properly assess Mr A's condition. She said that the clinical records were sparse and lacked evidence of examination, of thorough clinical assessment, and of thorough assessment of Mr A's pain.
With regard to Mr A's food and fluid intake, she said that records showed that he lost 8.7 kilograms over a two-month period, or 16.5 percent of his body weight. This was a significant amount and she would have expected a GP to physically examine their patient to rule out any underlying cause for weight loss. She would also have expected a GP to have either made urgent arrangements for a dietician to assess the patient or to have provided simple food supplements until the dietician could attend. She noted that, under the Lothian Joint Formulary Guidelines, Mr A should have been given a MUST score ('Malnutrition Universal Screening Tool', British Association for Parenteral and Enteral Nutrition). As he had lost so much weight, he would have received the maximum MUST score, identifying the necessity of food supplements and regular monitoring.
It was thought that Mr A may have been suffering from dehydration and also possibly have a urine infection. The adviser considered that the care and treatment for these issues were not reasonable, as there was a delay in prescribing an antibiotic to treat the suspected urinary tract infection and the management plan to deal with the dehydration was not changed despite there being no improvement for weeks.
With regard to the GP's suggestion of not intervening but keeping Mr A comfortable in the unit, the adviser commented that the diagnosis of dehydration and a possible urinary tract infection were both easily treatable. She added that Mr A was malnourished and losing weight, yet there was no evidence of investigation or examination. The adviser said that the suggestion of not actively investigating or treating these potentially reversible conditions, in a patient in a unit that aims to rehabilitate patients for home, was not a reasonable standard of care.
My investigation found that the overall care provided to Mr A during the period following his fall until his readmission to hospital was not of a reasonable standard and so I upheld Miss C's complaint and made several recommendations.
Redress and recommendations
The Ombudsman recommends that the Practice:
- (i) carry out a further significant event analysis in partnership with their local clinical director. This should include consideration of: how they ensure continuity of care for their patients and regular review of those most vulnerable; GP1's suggestion of keeping Mr A comfortable in the Unit, rather than addressing his potentially reversible conditions; the need for good record-keeping and ensuring thorough recording of clinical information in a patient's medical record, so as to assist in continuity of care; and consideration of the Lothian prescribing guidelines for urinary tract infections.
They should also consider referring this significant event analysis to NHS Education for Scotland for review; 31 December 2015 - (ii) familiarise themselves with the MUST scoring and Lothian guidelines for prescribing oral nutritional supplements; 30 October 2015
- (iii) take steps to ensure that other patients they care for in the Unit are receiving adequate treatment for malnutrition in line with the Lothian guidelines, where appropriate; and 27 November 2015
- (iv) issue a written apology to Miss C for the failings identified in this report. 30 October 2015