A practice in the South Oxfordshire area

5. Mr A complains about the care his mother, Mrs A, received from the Practice in 2024. He complains the Practice:

• incorrectly diagnosed from photos that Mrs A’s legs were infected and at risk of sepsis • did not prescribe antibiotics to treat the identified infection • incorrectly alleged that Mrs A’s daughter was providing poor nursing care and incorrectly referred Mrs A to social services.

6. Mr A says the referrals to social services meant the police were able to gain access to Mrs A’s home. He says they took photographs of her wounds and dressings, which the Practice then commented on. He says this resulted in Mrs A being incorrectly and forcibly removed from her home and placed into care. He says Mrs A died in December 2024, unhappy and cut-off from her family and familiar surroundings.

7. Mr A is seeking acknowledgement of mistakes, service improvements and financial remedy.

8. Mrs A was an elderly woman who had previously lived with her daughter, K. The Practice had previously made several safeguarding referrals regarding Mrs A’s care, which was often delivered by her daughter. Mrs A had spent the year prior to July 2024 living in a care home adjacent to the Practice.

9. In June 2024, K removed Mrs A from the care home and took her to live with her. At the end of June, the Practice made a safeguarding referral to social services.

10. In July 2024, K refused district nurses permission to enter the house and treat Mrs A for leg ulcers, which she had suffered with for some time. K told the nurses and Practice staff she was qualified to dress the ulcers herself as she was a former nurse. The Practice did not have evidence to corroborate this.

11. In early August 2024, police visited the house and negotiated access to the building. They took photos of Mrs A’s legs and dressings.

12. In mid-August, the local authority social care team emailed the Practice seeking a clinical comment on the photos. A Practice GP replied the same day and advised Mrs A needed medical attention. They said Mrs A’s legs were at risk of infection and if left untreated, were at risk of becoming septic.

13. The same day, the Clinical Director at the local NHS Trust emailed the social care team and advised that while the wounds did not appear to be infected, Mrs A was lucky no further harm had occurred and the current situation was not an appropriate management plan. The Practice exchanged further emails with the social care team later in August.

14. In September 2024, Mrs A was taken into care. She sadly died in December 2024.

The Practice incorrectly diagnosed from photos that Mrs A’s legs were infected and at risk of sepsis

18. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

19. The records show the local authority social care team emailed the Practice in August 2024 seeking clinical comment on photographs of Mrs A’s legs. A Practice GP replied the same day expressing concern about Mrs A’s safety. They said from review of the photos, it was likely Mrs A’s legs were infected and that she required input from district nurses to apply dressings. They said if care was not provided, Mrs A would be at risk of sepsis.

20. GMC ‘Good Medical Practice’ says clinicians should adequately assess a patient’s condition and symptoms, carry out a physical examination where necessary and promptly provide suitable advice.

21. GMC ‘Professional Standards: raising and acting on concerns about patient safety’ guidance says medical professionals have a duty to raise concerns where they believe patient safety or care is being compromised. It says clinicians have a duty to put patients’ interests first and to act to protect them.

22. Our adviser said that while the photos were from a single day rather than over several days, one leg appeared to be red and swollen with some tender and loose skin, especially compared with the other leg, which could be indicative of infection. They said the suggestion of a possible infection was clinically appropriate.

23. Our adviser said the GP appeared to have considered Mrs A to be an adult at risk, given the context of the relationship between Mrs A’s daughter, K, and the Practice, and previous safeguarding referrals which had been made for Mrs A. They said the GP appropriately assessed the photos of Mrs A in line with GMC guidance on patient safety.

24. Our adviser said that while a full assessment and diagnosis would not be possible from a photo, it was in line with guidance and standard practice for the GP to reach an indicative diagnosis from a photograph. They said it is now standard practice for GPs to request photos of wounds and possible infections prior to an in-person assessment. They said the GP had a professional responsibility to look at the photographs and gave their honest assessment based on the information they had.

25. We recognise Mr A’s concern that the Practice GP incorrectly diagnosed Mrs A with an infection based on photos of her legs. Having reviewed the evidence, we are satisfied the Practice acted in line with both sets of GMC guidance when it raised concerns over a possible infection. We will therefore not be looking at this part of the complaint further.

The Practice did not prescribe Mrs A antibiotics to treat the identified infection

26. The records show that following the GP’s assessment of the photographs of Mrs A’s legs in August 2024, the Practice GP did not prescribe Mrs A antibiotics or any other medication. The Practice documented the belief that antibiotics were necessary and that Mrs A needed a physical assessment by a medical professional.

27. GMC ‘Good Medical Practice’ guidance says clinicians should prescribe drugs or treatment only when they have adequate knowledge of the patient’s health and on the best available evidence.

28. NICE guidance on the diagnosis of cellulitis says clinicians should physically examine the patient before confirming the diagnosis and proceeding to treatment.

29. Our adviser said the Practice GP’s decision not to prescribe Mrs A antibiotics following the indicative diagnosis made from photographs was in line with GMC and NICE guidance. They said given Mrs A’s age and the context of her care, the GP would have wanted to carry out a physical examination of Mrs A before prescribing antibiotics, which is also specified in NICE guidance prior to a diagnosis of cellulitis.

30. Our adviser said Mrs A would have required assessment and observations, and swabs may have been taken, making physical assessment essential prior to any prescription of antibiotics. They said given the complexities of the patient and daughter’s relationship with the Practice, recent police involvement and the fact the Practice had no recent medical history for Mrs A, it was correct Mrs A was not prescribed antibiotics based on assessment from a photograph.

31. We recognise Mr A’s concern that the Practice incorrectly decided not to prescribe antibiotics to Mrs A, having made an indicative diagnosis of an infection. Having reviewed the evidence, we are satisfied the Practice followed relevant GMC and NICE guidance when it decided not to prescribe antibiotics without a physical assessment. We will therefore not be looking at this part of the complaint further.

The Practice incorrectly alleged Mrs A’s daughter, K, was providing poor nursing care and incorrectly referred Mrs A to social services

32. The records show the Practice had long standing concerns over K’s care of Mrs A and had made several safeguarding referrals in previous years.

33. In June 2024, the Practice made a safeguarding referral to social services for Mrs A after she was removed from her care home by K.

34. In August 2024, in an email exchange with the local authority social care team, a Practice GP documented their belief that Mrs A was not safe in K’s care and should be removed as soon as possible. They said they believed K had obstructed outside care for Mrs A’s legs on a regular basis.

35. GMC ‘Good Medical Practice’ says clinicians must act promptly if they think patient safety is, or may be, seriously compromised.

36. GMC ‘Professional Standards: raising and acting on concerns about patient safety’, says medical professionals have a duty to raise concerns where they believe patient safety or care is being compromised. It says clinicians have a duty to put patients’ interests first and to act to protect them.

37. The records show the Practice had longstanding concerns for Mrs A’s safety and her care by K. Our adviser said the Practice referred Mrs A to social services out of concern for her best interests and her overall wellbeing. They said the referral was justified given the clinical context and the historical context of concern for Mrs A’s care and safety. They said Practice GPs had acted in line with guidance and professional responsibilities when making the referral.

38. We recognise Mr A’s concern that the Practice incorrectly referred Mrs A to social service. Having reviewed the evidence, we are satisfied the Practice followed GMC guidance when it made a safeguarding referral for Mrs A in June 2024. We will therefore not be looking at this part of the complaint further.

39. We thank Mr A for taking the time and effort to bring his complaint to our attention. We recognise this was a very difficult and distressing period for him, following which Mrs A sadly died. We hope our explanation provides reassurance that the Practice cared for and treated Mrs A in line with relevant guidance. We offer Mr A our condolences and wish him the best for the future.

1. We have carefully considered Mr A’s complaint about the care his mother, Mrs A, received from the Practice in 2024.

2. We are very sorry to hear Mrs A’s experience caused her and Mr A distress.

3. We have seen no indication anything went wrong in the Practice’s care and treatment of Mrs A. We consider the Practice GP’s diagnosis that Mrs A’s legs were at risk of infection was clinically appropriate and the decision not to prescribe antibiotics without an in-person assessment was in line with guidance. We consider the Practice’s decision to refer Mrs A to social services was intended in her best interests, and was justified given the clinical context and historical context of concern about her care.

4. We hope our explanation below reassures Mr A the Practice assessed, cared for and treated Mrs A in line with relevant guidance.