A practice in the Thanet area

4. Mrs R complains about the care provided to her father, Mr N by the Practice in March 2025, before he sadly died on 7 April 2025. Specifically, she complains on 21 March 2025, the Practice failed to follow the instructions in his ReSPECT form to assess him and arrange end of life care at home.

5. Mrs R says as a result her father suffered a ‘bad death’ in hospital against his wishes of staying at home. She says the Practice let him down and if he had received the end of life care he wanted at home, it would have been far more comfortable for him.

6. As a result of bringing this complaint to us, Mrs R is seeking for the Practice to admit its failing, apologise and make service improvements.

7. Mrs R’s father, Mr N was 96 years old at the time of the events complained about.

8. In the early hours of 21 March 2025 Mrs R received a call from the ‘life line’ service to let her know her father was unwell and her husband went to his house to find him unwell.

9. Paramedics came out and wanted to take Mr N to hospital but he refused as per the wishes in his ReSPECT form. Mrs R contacted the GP the same day to ask for a home appointment to arrange end of life care at home. The Practice said they would be unable to come out that day and as he already had an appointment booked for a few days later on 24 March they would review him then.

10. Following this, Mr N’s condition deteriorated further so paramedics attended again twice over the following days and he agreed to be taken to hospital. He went into hospital with a suspected Urinary Tract Infection (UTI), infection in his leg and pneumonia in his right lung. He sadly died on 7 April 2025.

11. Mrs R complained to the Practice on 1 April 2025 and the Practice sent its response on 6 May 2025. Mrs R brought the complaint to us on 7 August 2025.

14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative impact which the organisation has not remedied.

15. Mrs R confirmed when we spoke to her that father suffered a ‘bad death’ in hospital against his wishes of staying at home. She says the Practice let him down and if he had received the end of life care he should have at home, it would have been far more comfortable for him. She says the felt the Practice complaint response was missing an apology and compassion for what the Practice put her father through.

16. Mrs R was dissatisfied with the Practice response which prompted her to bring the complaint to PHSO.

17. We requested the relevant records from the Practice and it provided these. From reviewing these we could see indications of failings in relation to the care the Practice provided to Mr N.

18. The Practice’s appropriate home visit policy was not followed as it should have been and the call Mrs R made to the Practice should have been discussed directly with the duty GP rather than escalated via the reception manager as palliative, elderly and vulnerable patients should be prioritised via the duty GP hub. The Practice acknowledged this in its response to our request for the records.

19. Our Principles for Remedy say to put things right organisations should provide an apology and remedial action.

20. We contacted the Practice on 26 January to ask whether it would be willing to write Mrs R a sincere apology letter for the lack of home visit which recognises and acknowledges the impact caused. We also asked the Practice to include an explanation of the learnings taken and the service improvements it has made to prevent this happening again

21. The Practice confirmed to us via email on 4 February that it would be willing to send the apology letter including explanations of its learnings and service improvements it has made. The Practice confirmed it will send this to Mrs R by the end of this month.

22. We contacted Mrs R by email on 4 February to explain the resolution agreed by the Practice. Mrs R confirmed she was satisfied with this as an outcome to the complaint. As she has confirmed this, will take no further action.

23. Complaints give us a valuable insight into the organisations we investigate, we recognise this was a distressing experience for Mr N and his family and do not underestimate the impact caused. We would like to thank Mrs R for sharing this experience with us.

1. We have carefully considered Mrs R’s complaint about the Practice.

2. The Practice has agreed to provide a formal written apology and implement service improvements to remedy Mrs R’s complaint.

3. We have decided the Practice has now done enough to remedy the complaint as it has agreed to provide the resolution Mrs R is looking for.