A medical centre, which was run by a group of GPs, failed to adequately manage Ms D's care. She later developed cellulitis (a bacterial skin infection) and died of multiorgan failure associated with septicaemia (blood poisoning caused by the spread of infection).
What happened
Ms P, the complainant, told us that in spring 2013 her mother, Ms D, saw her usual GP at the medical centre about fluid that was building up in her legs. The GP decided that Ms D should wait for an upcoming review with her heart specialist, and planned to discuss her care with her kidney specialist.
Later the same month, Ms D saw a locum GP from the medical centre about the same problems. The locum GP noted that the fluid was leaking, and recommended that Ms D dress, bandage and elevate her legs. She also contacted the district nursing team to help Ms D with this treatment.
The district nurse contacted the medical centre on her first visit because Ms D's right leg was discoloured. A different (third) GP visited Ms D at home that day and diagnosed her with cellulitis. He prescribed oral antibiotics.
Shortly after, the district nurse contacted the third GP at the medical centre again because Ms D's cellulitis had worsened. The third GP arranged for Ms D to go into hospital that day.
Ms D died in hospital soon after. Her death certificate records her cause of death as multiorgan failure, septicaemia and cellulitis.
What we found
Ms P raised several issues about her mother's care and treatment from the medical centre. We did not uphold all aspects of her complaint.
However, the medical centre should have referred Ms D to the district nursing team when the first GP saw her. When she saw Ms D, the second GP should have arranged an urgent referral to the district nursing team to dress Ms D's legs in a sterile way, and/or considered prescribing antibiotics. In addition, the third GP should have arranged for Ms D to go into hospital for intravenous antibiotics when he visited her at home.
While we could not say that Ms D would not have died when she did, the medical centre should have taken action that might have prevented the development and spread of cellulitis and consequent septicaemia.
Ms P and her sister will now never know whether things could have been different if their mother had received the treatment that she needed from the medical centre. This has been, and will continue to be, a source of continual upset and distress to them.
Putting it right
After our report, the medical centre acknowledged and apologised for its failings, and put together an action plan that demonstrated that it had learnt from its mistakes.
A medical centre
Merseyside
Replied with inaccurate or incomplete information
Apology
Recommendation to learn lessons or draw up an action plan