Failings in out–of–hours GP care for Alzheimer's patient after he attacked his wife

What happened

After this incident, Mr B's son, Mr P, tried to get help from NHS 111 and social services but he had difficulty getting a doctor to assess his father. The incident happened over a bank holiday weekend and there was only one social worker on duty to provide out–of–hours mental health assessments in the county. She decided that Mr B did not need to be assessed urgently, given that Mrs B had left the house, and because of other, more urgent, cases.

Early the next evening, a triage GP, who Mr P had contacted through the 111 NHS service had left a message for the out–of–hours mental health services asking them to call back, but they did not. Mr P eventually managed to get an out–of–hours GP to visit his father later that evening. The out–of–hours GP carried out an assessment of Mr B's mental state by asking him ten simple factual questions but found no evidence of confusion.

The out–of–hours GP spoke to Mr P on the phone and then waited for him to arrive at Mr B's house. There were conflicting accounts about whether the out–of–hours GP made efforts to contact the mental health services' out–of–hours number. The out–of–hours GP did not feel that he could do more for the Family and advised them that this was a domestic issue and they should seek advice about Alzheimer's from Mr B's own GP when the surgery reopened (which would have been two days later).

Mr P was extremely unhappy and felt that his mother's wellbeing had been jeopardised by the failure of the out–of–hours GP to take action. He arranged for another out–of–hours GP to visit the following day, and she diagnosed a possible urine infection and prescribed antibiotics. When Mr B's GP surgery reopened, Mr B's son and daughter persuaded him to attend, and staff carried out a mental health assessment. Mr B was admitted to hospital under a section of the Mental Health Act and remained there for a number of weeks.

What we found

We partly upheld this complaint. The first out–of–hours GP had not documented appropriate attempts to rule out a physical cause for Mr B's confusion, in particular a urine infection. He said in a statement that he had made multiple calls to the out–of–hours mental health services but he had not documented these either. We did not feel that the care he gave was in line with established good practice, or that it was reasonable for the first out–of–hours GP to treat this incident as a domestic dispute, given Mr B's Alzheimer's and his very uncharacteristic behaviour.

That said, we did not think that the outcome would have been very different even if the first out–of–hours GP had acted in line with established good practice. The staffing situation over the bank holiday weekend meant that there was only one social worker covering the whole county. This was a distressing situation for the Family and a complex one in terms of the overlapping responsibilities and communication difficulties between different agencies.

However, we did not feel that the distress was solely caused by the failings we identified.

Putting it right

The Clinical Commissioning Group apologised to the Family and took action to make sure that record keeping by the out–of–hours agency's GPs was in line with General Medical Council guidance, following an audit that was already underway.