GP practice deferred home visit and failed to monitor diabetic patient in her seventies.

What happened

Mrs G had multiple health problems including a heart condition, chronic kidney disease, and type 2 diabetes. Her diabetes was not well controlled so the practice increased her medication, which led to gastric side effects. Ms D, Mrs G's daughter, asked the practice for a home visit. The practice agreed to this, and Ms D asked it to contact her if necessary.

A GP telephoned Mrs G directly because the practice's usual procedure for arranging home visits had failed. Mrs G was confused, and her husband told the GP it was not urgent. Ms D said her parents would not wish to trouble or inconvenience a doctor, but the home visit was urgent. The following day Mrs G collapsed. She was unable to be resuscitated and died at home.

What we found

The decision to defer the home visit was unreasonable as the practice did not carry out a robust assessment because of Mrs G's confused state. The practice had agreed to speak to Ms D; when it could not contact her it should have gone ahead with the home visit as planned. There was a missed opportunity for Mrs G to get the treatment she needed for her heart condition. We could not reach a view on whether Mrs G's death could have been prevented if the visit had gone ahead as planned.

It was unreasonable for the practice to increase Mrs G's diabetes medication without regularly monitoring her kidney function. This possibly played a part in Mrs G's death.

Putting it right

The practice apologised to Ms D. It also changed its procedures to make sure that appropriate supervision arrangements were in place for trainee doctors who are on call and to make sure that the workload for trainee GPs on call is manageable and does not affect patient care. The practice will also audit all diabetic patients who have kidney failure, to make sure that their medication is appropriate and that their kidney function has been adequately monitored.