GP's diagnosis without assessment delayed treatment

What happened

Mrs M (Mrs N's mother) had dementia, took blood thinning medication and had a history of urinary tract infections (signs of which included agitation). She had recently moved to a care home and changed her GP to a local practice.

Mrs M became agitated a few weeks after moving to the home and staff called her new GP. The GP did not visit the home or examine Mrs M, but prescribed quetiapine – an antipsychotic drug. Mrs M continued to deteriorate. The care home staff reported that she was bleeding from her mouth, and had poor mobility and a reduced appetite. A GP visited but could not see any fresh blood. He reduced her quetiapine. A few weeks later, the care home staff came to wake her and she had momentarily stopped breathing. Staff called an ambulance and Mrs M went to hospital. Mrs M died the following day of sepsis and a urinary tract infection.

What we found

The GP should not have prescribed Mrs M quetiapine without assessing her condition, history or circumstances. The GP should have arranged for a blood test when the care home staff reported seeing blood in Mrs M's mouth. Additionally, because there was no proper assessment when Mrs M was initially agitated, we cannot know whether Mrs M had an infection at the time. As such, there was a missed opportunity to accurately diagnose her. If the GP had completed a proper assessment and diagnosed Mrs M with a urinary tract infection, the correct treatment could have started.

Putting it right

The GP acknowledged her failings and apologised to Mrs N. The Practice drew up plans that showed what staff had learnt from the failings we identified, and what it would do to make sure that staff were up to date with current guidelines about medication.