The complainant (C), a representative of the Patient Advice and Support Service, complained to my office on behalf of A about the treatment A’s spouse (B) received from their GP practice (the Practice) between July and October 2020. B developed cellulitis (a bacterial infection of the skin) on one of their legs. Although B was treated with multiple courses of antibiotics, the infection did not improve. Following an allergic reaction to the antibiotics, B chose not to receive further treatment. Sadly, B’s condition deteriorated and B died.
C complained that the Practice prescribed five courses of antibiotics without seeing B and considered that a GP should have reviewed B face-to-face when the infection did not resolve. A complained that B was not told of the risks of refusing antibiotic treatment. A also considered that the Practice should have carried out blood and skin tests to ensure that an effective antibiotic was prescribed and that the Practice should have referred B to hospital for intravenous antibiotics when B’s condition did not improve.
The Practice detailed the contact they had with B and said that skin conditions such as cellulitis are treated by their Advanced Nurse Practitioners (ANPs) and that they considered the treatment offered to B had been appropriate. The Practice said that they would not recommend the referral of B to hospital due to the COVID-19 restrictions in place at the time.
I sought independent advice from a GP (the Adviser). The Adviser told me B should have been closely monitored and specialist advice should have been sought early on in B’s care pathway. The Adviser told me B should have been seen face-to-face at the first appointment and a doctor should have been involved after the first course of antibiotics failed to work and in line with NICE accredited guidelines, specialist input should have been sought after a second course of antibiotics failed to improve B’s condition and admission for intravenous antibiotics considered.
The Adviser also told me there were no restrictions in place preventing patients from being admitted to hospital should their condition require this between July and October 2020. The Adviser gave their view that the failings they had identified had contributed to B’s death.
In light of the evidence I have seen and the advice I received, I found that: the Practice did not provide reasonable care and treatment to B between July and October 2020. As such, I upheld C’s complaint.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Practice to do for A:
| Rec. number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
| 1. |
Under (a) we found that the care and treatment provided by the Practice to B between July 2020 and October 2020 was unreasonable. In particular that:
|
Apologise to A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets. |
A copy or record of the apology. By: 21 June 2023 |
We are asking the Practice to improve the way they do things:
| Rec. number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
| 2. | The care and treatment provided by the Practice to B between July 2020 and October 2020 was unreasonable. |
Patients presenting with symptoms suggesting cellulitis should be appropriately assessed including a face-to-face assessment and being appropriately monitored. If their condition does not improve treatment should be escalated in line with relevant guidance. |
Evidence that the Practice have:
Confirmation should be provided of the review and the changes implemented as a result of this review; how the guidance has been updated and disseminated, and how the training needs of staff have been addressed. By: 16 August 2023, with a progress update by 5 July 2023. |
| 3. | A Significant Event Analysis or similar reflective review should have been held. | Where there has been a significant adverse event a reflective review should be considered, and either a clear reason recorded as to why it was not carried out, or held, ensuring that events are considered against relevant standards and guidelines and that failings, and good practice, are identified and any appropriate learning and practice improvements made. |
Evidence that the Practice have systems and processes in place for reflective review of significant adverse events that support staff involved to identify learning and improvement By: 16 August 2023 |
We are asking the Practice to improve their complaints handling:
| Rec. number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
| 4. |
The Practice’s complaint response was unreasonable. There is no evidence to support the Practice’s recording that the complaint was acknowledged or that the complaint was responded to within 20 working days in line with the Model Complaints Handling Procedure. There was a failure to investigate and respond to all the concerns raised by C and provide an appropriate response that recognised the significance of the events for A and the impact of B’s death. The response was undated. |
The Practice’s complaint handling monitoring and governance system should ensure that:
Complaint responses are clearly dated and records reflect when and how they are shared. |
Evidence that the findings on the Practice’s complaint handling have been fed back in a supportive manner to relevant staff and that they have reflected on the findings of this investigation. (For instance, a copy of a meeting note or summary of a discussion.) By: 19 July 2023
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