Trust and out–of–hours GP service failed to give good care

What happened

Mr D had dementia, but was independent and looked after himself. In summer 2011, Mr D's health deteriorated and his speech became slurred. His wife, Mrs D, called the GP out–of–hours service, which did not visit but arranged for Mr D to go to a minor injuries unit. Staff at the minor injuries unit diagnosed Mr D with a possible heart attack or a stroke. Clinicians gave him medication and sent him to A&E at the Trust by ambulance.

Trust staff called to ask Mrs D and her family to go to the hospital to meet a consultant. When Mr D's family arrived at hospital, they learnt that Mr D had experienced bleeding, a stroke and a heart attack, and had pneumonia. Staff said that his death was imminent.

Mr D continued to deteriorate. He developed acute heart failure. During Mr D's last few days, there were several discussions between clinical staff and his family about his condition and the appropriateness of withdrawing treatment. He died soon after.

Mrs D expressed her concern about her husband's care and treatment from both the GP out–of–hours service and the Trust. Her main worry was that her husband's death could have been avoided.

What we found

We partly upheld Mrs D's complaint about both organisations. The GP out–of–hours service doctor, in his call to Mrs D, did not take account of or explore the significant symptoms she described. He should have considered these symptoms and offered an urgent home visit, if not a 999 ambulance. It was not possible, however, to say what difference an earlier assessment by the GP out–of–hours service doctor would have made to Mr D. He would have gone into hospital sooner, but only by a few hours. Given that Mr D was very seriously ill when his wife first contacted the GP out?of?hours service, the effect of a delay of a few hours would have been minimal. We recognised, however, that there was an impact on Mrs D, who felt that her concerns had not been listened to. This was a source of avoidable anxiety and upset to her at a time when she was already distressed.

With respect to the Trust, there was no evidence of delay in initial treatment or failings in how staff communicated with Mr D's family about his condition, the withdrawal of treatment and their concerns about his treatment. However, shortcomings in Mr D's care meant that he had incomplete treatment for his heart attack and heart failure.

Although the medical management of Mr D's heart attack and heart failure could have been better, he nevertheless had some treatment for both. However, he continued to deteriorate. On the balance of probabilities, Mr D might have survived for a day or two longer had he received maximum treatment in line with recommended guidance. However, the severity of his illness meant his death at this time was not avoidable.

Putting it right

The GP out–of–hours service apologised to Mrs D and prepared an action plan to show what it had done to prevent a recurrence of the problems we found.

The Trust apologised to Mrs D for the failings in Mr D's care. It prepared an action plan to show what it had done to make sure that it had learnt the lessons from the failings we identified, and what the Trust had done or planned to do to avoid a recurrence of these failings.