A practice in the Reigate and Banstead area

5. Mrs L complains about aspects of care and treatment she received from the Practice between April and September 2024.

6. Specifically, Mrs L said the Practice:

•did not refer her to urology or physiotherapy in April and May •delayed referring her to the older persons mental health team in May •incorrectly prescribed her with antidepressants in September.

7. Mrs L said she suffered prolonged pain and a decline in her physical and mental health. She also said Ms L’s mental health suffered seeing her health deteriorate.

8. Mrs L is looking for service improvements and an apology.

9. In March 2024, Mrs L had a fall in her home. An ambulance took her to hospital (Hospital A) where she was admitted.

10. In April, Mrs L had a failed Trial Without Catheter (TWOC) at Hospital A.

11. In the same month, Hospital A discharged her to a rehabilitation unit (Hospital B).

12. On the discharge letter, it said Mrs L was due to receive a TWOC at Hospital B.

13. At Hospital B, Mrs L had an unsuccessful TWOC.

14. In May, Hospital B discharged Mrs L back home.

15. On the discharge letter, it asked the Practice to refer Mrs L to urology for a TWOC.

16. Also on the discharge letter, Hospital B said Mrs L had two failed TWOCs while admitted.

17. Two weeks after Mrs L’s discharge home, Ms L told the Practice Mrs L’s mental health had deteriorated. She said Mrs L had commented that she wants to die.

18. On the same day, the Practice referred Mrs L to the community frailty service.

19. Four days later, Ms L called the community frailty team. She said Mrs L had made comments that she did not want to be here. The community frailty team told Ms L a referral to a mental health adviser would be sent.

20. Three days later, the community frailty team referred Mrs L to talking therapies.

21. In June, talking therapies spoke with Mrs L. It recommended short-term therapy with its service.

22. Four days later, Mrs L reported to the Practice that she cannot sleep due to catheter issues.

23. Eleven days later, Ms L called the Practice unhappy with a lack of support with Mrs L’s catheter care. She said the Practice should have referred Mrs L to urology for a TWOC. She adds Mrs L cannot sleep due to urine retention.

24. On the same day, the Practice told Ms L that urology was not appropriate for Mrs L. It said this was because Mrs L had three failed TWOCs previously.

25. In the same month, talking therapies spoke with Mrs L over the telephone.

26. After the telephone assessment, talking therapies wrote to Mrs L. It said as she did not remember the conversation about short-term therapy during their call, it recommended she is referred to the Community Mental Health Team for older people (OPCMHT) by the Practice. It said this information will be passed onto the community frailty team and the Practice.

27. Two days later, the Practice referred Mrs L to the OPCMHT.

28. In August, Ms L called the Practice chasing the referral to the OPCMHT. Ms L told the Practice the OPCMHT have advised it is waiting for information from the Practice to process the referral.

29. On the same day, the Practice contacted the OPCMHT.

30. One day later, the Practice referred Mrs L to the mental health crisis team.

31. Three days later, Mrs L and the Practice agreed to start her on an antidepressant.

32. In September, the Practice discontinued Mrs L’s antidepressants on her request.

33. In October, Mrs L was deducted from the Practice and moved to a care home.

The Practice did not refer her to urology and physiotherapy

36. Mrs L said following her discharge from Hospital A in April 2024, the Practice did not refer her to urology or physiotherapy, on the instruction of Hospital A.

37. The Practice said, in April the hospital transferred Mrs L to Hospital B for rehabilitation. It said Hospital A had sent Mrs L’s discharge notes to Hospital B and it would have been Hospital B’s responsibility to action any requests.

38. The Practice further said there were no requests from the Hospital A to refer Mrs L to physiotherapy.

39. From the evidence we have seen Hospital A discharged Mrs L to Hospital B April. Hospital B discharged her home in May. We understand it is on these two occasions we need to consider if the Practice had a responsibility to refer Mrs L to urology and physiotherapy.

40. In the discharge notes from Hospital A, it requested Hospital B should refer to Mrs L to urology for a trial without catheter (TWOC).

41. When Hospital B discharged Mrs L in May, it requested the Practice refer Mrs L to urology. Mrs L’s medical records show the Practice did not refer Mrs L to urology because she had already had three failed TWOCs, while she was in hospital.

42. There is nothing on the discharge notes from April and May asking the Practice to refer Mrs L to physiotherapy.

43. The Practice referred Mrs L to the frailty team in May to manage her health needs in the community. Frailty community teams are responsible for caring for patients with immobility and incontinence.

44. Our adviser said there is no specific guidance on how many TWOCs clinicians should attempt. They said after three previous failed attempts to remove Mrs L’s catheter, and considering her age and frailty, it was reasonable for the Practice to make the clinical judgement not to re-refer her to urology. They further said it was reasonable for the Practice to manage Mrs L with a long-term catheter.

45. General Medical Council (GMC), Good medical practice says, if you assess, diagnose, or treat patients, you must work in partnership with them to assess their needs and priorities. The investigation or treatment you propose, provide or arrange must be based on this assessment, and on your clinical judgement about the likely effectiveness of the treatment options.

46. Based on the evidence we have seen, the Practice did not need to refer Mrs L to physiotherapy. We cannot see any instruction from Hospital A or Hospital B for this referral. There is no indication that Mrs L required physiotherapy. We are satisfied the Practice did not need to refer Mrs L to physiotherapy services.

47. We can see the Practice acted in line with GMC guidelines in evaluating Mrs L’s needs for a urology assessment. We are satisfied the Practice made an appropriate clinical judgement about her treatment options for urology.

48. We can see it made the decision to refer Mrs L to the frailty team to manage her health conditions. We are satisfied the Practice took the appropriate action with Mrs L’s referrals at this time. We will not investigate this further.

The Practice delayed referring her to the community mental health team

49. Mrs L told us there was a delay in the Practice referring her to mental health services. She said she was in distress and felt suicidal. Ms L told us this time was stressful for her as she had to manage Mrs L’s worsening mental health with limited support.

50. Mrs L said the Practice referred her to the Community Mental Health Team (CMHT) in May. The CMHT identified she needed to be seen by the Older Persons Community Mental Health Team (OPCMHT).

51. As she had not heard anything from the OPCMHT about Mrs L’s referral, Ms L chased this in July. She told us she spent a great deal of time and effort over the weeks to chase this appointment. She believed there was an administration error with the Practice on the OPCMHT referral, which caused the delay.

52. The Practice said it sent the referral in a timely manner. It apologised for any delays Mrs L experienced in the OPCMHT contacting her.

53. Mrs L’s medical records show the Practice first recorded details of Mrs L’s poor mental health in May.

54. Four days later, the Practice contacted Mrs L’s frailty team to ask if it had sent a mental health referral for Mrs L.

55. Mrs L’s medical records show a discharge letter from talking therapies in June. This shows the frailty team referred Mrs L to its service in May.

56. We can see in June, the Practice referred Mrs L to the OPCMHT. It chased the referral in August.

57. Our adviser said the frailty team referred Mrs L to mental health services initially in May. The mental health service, talking therapies, identified Mrs L was not an appropriate patient for the service and discharged her in June. The Practice then referred Mrs L to the OPCMHT two days later. Our adviser considered this referral to be timely.

58. They said the referral letter from the Practice to the OPCMHT was appropriate. They said it explained the reason for referral and included the letter from talking therapies. Our adviser said they cannot see any inaccuracies with this referral.

59. They further said they cannot see any entries in Mrs L’s medical records from the OPCMHT requesting further information on Mrs L’s referral.

60. GMC Good medical practice says you must pass on to the medical, health, or social care professional or service provider involved relevant information about the patient’s condition and history.

61. It also says, you must promptly provide (or arrange) suitable advice, investigation or treatment where necessary.

62. We can see the Practice provided enough details to the OPCMHT in its referral for Mrs L in June. We consider this referral was in line with GMC guidance.

63. Having considered the evidence, we can see the Practice contacted the frailty team to ensure it had referred her to mental health services. This was within four days of Ms L explaining her mother’s mental health deterioration. We are satisfied the Practice referred Mrs L to the CMHT in a timely manner. We will not investigate this further.

The Practice prescribed her with antidepressants in error

64. Mrs L told us she trialled antidepressants for four weeks in August 2024 and decided not to continue with them. She said the Practice prescribed the antidepressants on a repeat prescription, after she decided to discontinue them.

65. Mrs L said was against her wishes and caused a decline in her overall faith in the Practice to appropriately manage her health. Mrs L believes she was taking this medication until early October.

66. The Practice said that it discontinued Mrs L’s antidepressants in September 2024. It said it issued antidepressants to Mrs L three weeks later, which was likely an error. This action was not linked to a consultation.

67. The Practice has apologised for this error. It has also said it reminded the administration team to carefully check repeat prescription requests to avoid reoccurrences.

68. GMC Good medical practice says you should, propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their need.

69. Based on what we have seen so far, the Practice incorrectly prescribed Mrs L antidepressant medication on a repeat prescription. This is an indication of a failing.

70. Our principles for remedy say, where maladministration or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. If that is not possible, the remedy should compensate them appropriately. Remedies should also be offered, where appropriate, to others who have suffered injustice or hardship as a result of the same maladministration or poor service. There are no automatic or routine remedies for injustice or hardship resulting from maladministration or poor service. Remedies may be financial or non-financial.

71. An appropriate range of remedies will include:

• an apology, explanation, and acknowledgement of responsibility • remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures to prevent the same thing happening again; training or supervising staff; or any combination of these • financial compensation for direct or indirect financial loss, loss of opportunity, inconvenience, distress, or any combination of these.

72. Our severity of injustice scale says a level one injustice is usually injustices such as annoyance, frustration, worry or inconvenience, typically arising from a single (one-off) incidence of maladministration or service failure. We would generally consider an apology to be an appropriate remedy for level one injustice.

73. The Practice has already apologised for the error. It has also reminded its patient administration team to check prescription orders to avoid recurrences.

74. We can see the Practice did not issue the antidepressants to Mrs L again after this error. We are satisfied the Practice has done enough to put things right. We will not consider this further.

Conclusion

75. It is clear from Mrs L’s medical records she was struggling with her physical and mental health at the time, and this undoubtedly had a profound effect on Ms L caring for Mrs L. We are sorry to learn about this experience. We thank Mrs L for bringing this complaint to our attention.

1. We have carefully considered Mrs L’s complaint about the Practice. We were sorry to hear her concerns about how the Practice managed her referrals and medication. From what she told us, this has clearly been a significantly distressing time for her and Ms L.

2. We have seen the Practice followed relevant guidelines when it managed Mrs L’s referrals to specialists after her discharge from hospital. Based on the information we have considered, we have seen no indications anything went wrong. We have decided to take no further action on this aspect of the complaint for this reason.

3. We considered Mrs L’s concerns about how the Practice managed her medication. From what we have seen, the Practice did not follow relevant guidelines when it managed Mrs L’s medication. We have considered the action the Practice has taken to remedy this part of the complaint. We are satisfied it has acknowledged and apologised for what went wrong. We have decided to take no further action on this complaint for this reason.

4. We recognise how important this complaint is to Ms L, and we would like to take this opportunity to thank her for bringing her complaint to our attention. We hope our explanations below show how we have considered this complaint.