GP failed to make home visits to older patient

What happened

Mrs S was discharged after a short hospital admission. Her symptoms of agitation, hallucination and unreasonable, out of character behaviour worsened and her family requested a GP home visit. For the following 15 days, her family had several telephone consultations with the GP, and he prescribed sleeping medication and antibiotics. But he did not make any more home visits to review and assess Mrs S and evaluate his treatment plan.

Mrs S was eventually readmitted to hospital, where she later sadly died.

What we found

The GP conducted an appropriate home visit but it was not reasonable that he did not return for more face–to–face assessments.

It was also not reasonable that the GP changed Mrs S's prescriptions and prescribed different medication over the telephone without having seen her. We did not conclude that any failing led to her later death but we felt if the GP had visited, Mrs S's medication management may have altered the course of her later hospital admission.

Putting it right

The GP involved in this complaint was a locum, employed by an agency commissioned by the Area Team. The Area Team sent Mrs S's son a letter of acknowledgement and apology for the failings and shared the information in our report with the locum's agency. It liaised with the agency to put into place action to prevent something similar happening again and to show learning.