A practice in the Coventry area

4. Dr T complains about how the Practice managed his father’s care and treatment from 2015, when he first presented with symptoms of a brain tumour. Specifically, Dr T says the Practice: • failed to make appropriate referrals despite his father presenting with symptoms of a brain tumour • did not carry out a home visit in June 2021 following his father’s diagnosis and discharge from hospital, despite the close proximity • did not check the medications Mr T required, meaning some medications ran out and was prescribed incorrect drugs • did not follow correct guidelines when referring his father for palliative care.

5. Dr T believes these failings caused his father unnecessary suffering. He is seeking an apology, an impartial explanation of any failings, and financial compensation.

6. Dr T was closely involved in his father’s care until his father died in October 2021. He raised the concerns with the Practice between October 2022 and August 2023 and received responses between November 2022 and November 2023.

7. Dr T brought his complaint to us on 29 February 2024.

Failure to refer to specialist services despite symptoms of a brain tumour

10. The Law says complaints to be brought to us within one year of the person becoming aware of the issue. We may consider complaints outside this timeframe only if there is a good reason for the delay. Where applicable we have asked Dr T’s for his reasons for approaching us outside of this timeframe.

11. Dr T first raised concerns about the lack of referral in correspondence with the Practice dated 18 October 2022, more than a year after his father died on 6 October 2021.

12. The Practice responded in November 2022 and informed him of his right to approach our service if he remained unhappy. Dr T came to us in February 2024, around a year and four months later.

13. We asked Dr T about the delay in raising the complaint with the Practice between October 2021 and October 2022. Dr T explained he spent that year reflecting on and processing his father’s death and the treatment he received. We understand how grief can affect a person’s ability to engage with formal processes.

14. When we asked about the delay in approaching our service after the Practice’s response in November 2022, Dr T told us he was diagnosed with post traumatic stress disorder (PTSD) in late 2021 and with a brain tumour in early 2023. PTSD is a condition of persistent mental and emotional stress caused by an injury of severe psychological shock. Dr T said his ill health made it difficult for him to bring the complaint to us sooner. We were very sorry to hear about Dr T’s own health concerns.

15. The evidence we have seen shows Dr T was in significant correspondence with the Practice between November 2022 and February 2024. He raised other complaints, submitted information requests, and actively engaged in settlement discussions with the Practice. He was also in contact with our service about a separate complaint regarding the care agency involved in his father’s care.

16. While we are sympathetic to Dr T’s health issues, the evidence we have seen shows he was able to manage other matters during this period and could also reasonably have raised this complaint with our service within our time limit.

17. We do not consider his explanation demonstrates he was unable to progress his complaint sooner. For this reason, we have decided there is no evidence of sufficient grounds to set aside our time limit and consider this part of his complaint.

Lack of home visit following discharge

18. Before deciding whether to conduct a detailed investigation, we consider whether there are signs of service failings or maladministration that the organisation has not addressed.

19. Dr T says the Practice failed to visit his father between June and July 2021 despite his clinical need and his proximity to the surgery, which Dr T describes as being next door.

20. The Practice’s complaint response explained that it does carry out home visits, but typically only when patients or their relatives request them.

21. GMS guidance explains when a GP should do a home visit. It assumes a request for a home visit has been made by a patient (or suitable representative). It states that GP practices have discretion to decide whether a home visit is appropriate.

22. The records do not show Dr T or his father made a request for a home visit. We have not seen an indication the Practice did not act in line with GMS guidance as a request was not made.

23. We understand Dr T’s view that given the Practice was aware of his father’s poor health it should have proactively arranged to visit him. We also recognise the limited capacity of GP practices.

24. Taking these factors into account, we cannot see the Practice failed to do a home visit when it should have. We do not consider there are indications of failings in this part of Dr T’s complaint. This means we will not look at this part of the complaint any further.

Medication – running out and incorrect prescriptions

25. Due to the demand for our services, we focus on the more serious complaints where people may have faced a significant impact, such as a potentially avoidable death or prolonged pain. These are the cases where we can make the greatest difference.

26. This means we do not look into complaints where the impact appears smaller. Based on the information provided, we consider this applies to this aspect of Dr T’s complaint.

27. Dr T told us that as the Practice did not check the medications due to his father. As a result, he ran out of some medications and was prescribed incorrect drugs. We reviewed the documents and discussed this with Dr T.

28. We understand the issues related to Aspirin (medication used for pain relief and to manage inflammation), ibuprofen gel (a gel applied to the skin to give targeted pain relief and manage inflammation), laxatives (medication used to increase bowel movements), and the need for sugar free medication due to his father’s diabetes.

29. Dr T says this meant his father experienced avoidable pain, he was put at risk of complications from his diabetes, which could have been deadly, and excessive laxatives could have caused him discomfort.

30. We recognise the worry caused by these medication errors. We have asked Dr T for details of the whether this matter had worsened Mr T’s condition, but he has not been able to explain significant impacts this has had. We have also reviewed the medical records and correspondence Dr T has held with the Practice none of which described any significant impacts.

31. For us to consider a complaint, we must see evidence of a service failing that led to a significant impact.

32. We recognise that issues with medication can be stressful, and we explored what further impact this had. However, we have not been provided with evidence of a significant impact that would mean it is proportionate for us to use our limited resources to investigate further. We hope our review of the records reassures Dr T we have seen no significant impact here.

Palliative care referral

33. The Practice referred Mr T for palliative care (specialist support for people with serious illness) in June 2021, but Dr T says the Trust did not provide palliative care to his father and he was not able to die at home as he wanted. Dr T says this was because the Practice did not fully complete the referral. We were very sorry to hear about the circumstances of Mr T's death.

34. Mr T’s medical records show on 29 June 2021 the Practice sent the Trust a palliative care referral. On 29 June the palliative care team were in discussions with the Practice about what care and support was available. This included Continuing Healthcare (NHS funded care provided in a nursing home), and psychological support. The palliative care team confirmed it was unable to put any further care in at Mr T’s home.

35. Based on the information we have seen to date the Practice referred Mr T, the referral was accepted, and the palliative care team were involved in Mr T’s care planning. We cannot see any indication the care was not provided on account of a failure in the referral process, as Dr T claims.

36. We also recognise it is not within the Practice’s control to provide the palliative care itself or to dictate how it should be delivered.

37. For these reasons we cannot link the claimed injustice of being unable to die at home to the Practice’s actions. We will not consider this part of his complaint any further

Conclusion

38. For the reasons outlined above, we will not be taking any further action on Mr T’s complaint about the Practice. We hope our explanations clearly explain our rationale for our decision.

39. We acknowledge this decision will be disappointing for Dr T, given the time and effort he has invested. We thank him for bringing his complaint to us and appreciate the opportunity to consider it.

1. We have carefully considered Dr T’s complaint about the care a GP Practice in the Coventry area (the Practice) provided to his late father Mr T. We appreciate how difficult it can be to revisit events surrounding a loved one’s illness and death. We are sorry to hear about the distress Dr T has experienced, and we recognise the effort he has made to raise these concerns.

2. After reviewing the available information, we have decided Mr T’s complaint about his father’s referral for specialist services is outside of our time limit. We have also seen no signs anything went seriously wrong with the home visit and medication aspects of Dr T’s complaints. Nor can we link the Practice’s referral to palliative care services to the location of Mr T’s death. We understand this may be hard for Dr T to hear, given the significance of these events for him.

3. We have set the reasons for our decision in full below. We hope our explanation reassures Dr T of the careful consideration we have given to his concerns.