A practice in the Gateshead area

5. Mr C complains staff from the Practice and the Trust inappropriately lifted (drag lifted) his father after a fall at a care home in October 2023. He also says the staff members did not inform him about the fall or the lift, and they did not report the incident to the Practice and the Trust. He has a further complaint the Practice did not diagnose his father with scabies in December.

6. Mr C says it was distressing to learn about the event from October through a television show. He says it was an emotional time for him. He adds his father was a vulnerable person and feels like the staff from the Practice and Trust, were their eyes and ears in the care home for someone like his father. He explains he no longer trusts the NHS and feels let down.

7. Mr C explains his father was confused when he started with a rash in December. He says he was tearing his skin out and it caused him pain. He also says his mother caught scabies off his father which caused her pain too and they were scared about what was happening. By making his complaint, Mr C wants an acknowledgement and a financial remedy.

8. Mr P was a man in his early 80s with a history of Alzheimer’s. He became a resident at a care home in late 2023. In early October the care home staff found Mr P on the floor. A general practitioner (GP) and nurse reviewed Mr P and found he had not sustained any injuries.

9. In mid-December the GP assessed Mr P at the care home and noted he had a chesty cough and fever. They prescribed him with antibiotics. They assessed him the following week and documented he had a widespread rash. It prescribed him with treatment for his rash. Another Trust admitted him a few days later after a fall at the care home. He sadly died a week later.

Inappropriate lift 12. Mr C complains a GP from the Practice and a nurse from the Trust inappropriately lifted his father when he was found on the floor at the care home. He told us he did not find out about the incident until it was aired on television a couple of months later, and we recognise how distressing this was.

13. The evidence we have seen suggests the care home staff found Mr P on the floor. In the responses from the Trust and the Practice, they explain the GP and the nurse were at the care home reviewing other residents. Care home staff asked them to attend to Mr P and check him for any injuries. The GP says it did not appear Mr P had suffered any injuries.

14. Mr C told us he saw blurred footage of the event on a television show in December. He says based on the footage he saw, he believes the GP and the nurse were involved in lifting his father from the floor and into a wheelchair. He says it was an inappropriate lift as they lifted him from underneath his armpits.

15. The GP explained they were present during the lift, but they did not physically take part in lifting Mr P from the floor. The nurse has also acknowledged they were there when Mr P was lifted into a wheelchair. They explained their contact was limited when they touched him on the upper arm to complete the movement safely. The GP and nurse have provided clear explanations, stating they did not physically carry out the act of lifting but were present.

16. We were not present at the time of these events and therefore cannot confirm exactly what happened or determine who was involved in lifting Mr P based on the evidence available. We note Mr C’s concerns based on the blurred footage he saw and acknowledge his opinion, of what happened, is different to what the GP and nurse have explained.

17. We have considered this carefully and we do not think there is sufficient evidence to be able to reach a robust view on what happened, or to establish which account is the correct one. Therefore, we do not think an investigation would provide further clarity or reach a satisfactory conclusion for Mr C.

18. For the reasons explained and based on the limited evidence available, we will not take further action on this matter. We acknowledge how upsetting this experience has been for Mr C. We hope he is reassured the evidence suggests Mr P did not sustain any injuries during either the fall or the process of being lifted. We hope this clearly explains what we have considered and how we have come to our decision.

Communication/reporting 19. Mr C also complains the GP or the nurse did not tell him about the fall or the lift, and they did not report the incident to the Practice and the Trust. We understand how difficult it was for Mr C to learn about his father’s fall in the way he did. We recognise from what he has told us this has caused him to question the actions of NHS staff involved.

20. There are no guidelines to specify whose responsibility it is to contact a resident’s family or report an incident. However, CQC guidance says when more than one provider is responsible for the safety of a person using services, the responsibility for providing safe care rests with the principal care provider at the time it is given. A principal care provider is the main organisation responsible for a person's safe care at any given time.

21. There is no evidence to suggest the GP and the nurse planned to visit Mr P as part of their ward round. Their involvement appears to be limited to providing a clinical assessment at the care home staff’s request. In Mr P’s case there is no indication the Practice or the Trust assumed responsibility of the principal care provider during these circumstances.

22. In response to Mr C’s complaint, the care home confirmed it referred the incident to the council’s safeguarding team as soon as it confirmed his father’s identity after the television show had aired. Based on this, it appears the care home acted in the capacity of the principal care provider in relation to both the event and its reporting.

23. We understand there has been a separate investigation by the Local Government and Social Care Ombudsman into Mr C’s complaints about the care home. The care home does not fall within our remit.

24. Based on the information we have seen, there is no evidence that either the GP or the nurse was acting as Mr P’s principal care provider, as outlined in the CQC guidance. They were present on site to support other residents and care home staff asked them to carry out an unplanned assessment of Mr P. Therefore, it does not appear they got anything wrong when they did not inform Mr C about the incident, or raise it with their associated organisations, as it was not their responsibility.

25. We recognise Mr C’s concern about how he found out about this incident. In reaching this decision, we are in no way underestimating the impact this had on Mr C or his family.

Scabies 26. Turning now to Mr C’s complaint the Practice did not diagnose his father with scabies in December 2023. Understandably, he is concerned about his father’s rash as he told us it was painful for him, and he was confused about what was happening. He also told us his mother was diagnosed with scabies around the same time which we recognise was worrying for her and the family.

27. Scabies is an itchy rash caused by mites. It often affects skin between the fingers, around wrists and under arms.

28. GMC guidance says if doctors assess, diagnose or treat patients, they must adequately assess the patient’s conditions, taking account of their history where necessary, examine the patient. It also says they must promptly provide or arrange suitable advice, investigations or treatment where necessary.

29. Mr P’s records show, in early December, the care home first noticed he had a rash. It called the Practice to request an appointment for Mr P. The Practice did not have any available appointments but signposted the care home to a rapid response team. A rapid response team provides urgent short-term health interventions to stabilise residents.

30. A GP from the Practice assessed Mr P a few days later. They noted he was unwell and prescribed him antibiotics for an infection. There is no indication Mr P had a rash during this assessment. It appears the GP followed GMC guidance by assessing Mr P’s condition and provided prompt treatment in the form of antibiotics. In the absence of a rash, there is nothing to suggest they should have provided any further treatment.

31. The GP carried out a further assessment the following week. They noted a widespread, dry and itchy rash. They considered the rash did not appear consistent with scabies, such as there was no rash in between Mr P’s fingers, which is common with scabies. They prescribed a steroid cream for irritated skin, a medication for an allergic reaction for the itch and a cream for his whole body.

32. Our adviser explains rashes can have several causes including a side effect of antibiotics which the GP had prescribed for Mr P the week before. They say overall it does not appear he had the classic signs of a scabies rash.

33. Based on the evidence we have seen, it does not appear Mr P’s rash was consistent with a typical scabies rash and there is no evidence to suggest he was diagnosed with scabies before he sadly died.

34. We can see the GP’s actions were in line with GMC guidance when it assessed and examined Mr P during both his appointments in December. We can also see it promptly provided him with treatment for his rash when he presented with this symptom.

35. We understand Mr C is concerned his father’s rash was scabies which was worrying for him, given it is contagious and his family were visiting him in the care home. We hope he is reassured we saw no indications of failings in the Practice not diagnosing his father with scabies.

1. We have carefully considered Mr C’s complaint about a GP Practice in Gateshead (the Practice) and Gateshead Health NHS Foundation Trust (the Trust). We are sorry to hear of Mr C’s concerns about the actions of both organisations. He is concerned about what happened to his father, Mr P, and he has explained this has caused him to lose trust in the NHS.

2. We have reviewed the evidence provided by Mr C, the Practice and the Trust. We considered Mr C’s concern that staff from the Practice and the Trust inappropriately lifted his father off the floor in October 2023. We have not seen any evidence to support us in making an impartial decision about this matter. We understand this outcome may be difficult for Mr C as it does not provide the certainty or resolution he might have hoped for.

3. We did not see indications the staff got anything wrong when the Practice or Trust did not contact Mr C about the incident or report it to their relevant organisations. There is also evidence the Practice followed relevant guidelines when it assessed his father’s rash in December 2023.

4. Therefore, we will not take further action on this complaint. In coming to our decision, we are not diminishing the impact Mr P’s experience has had and continues to have on Mr C and their family. We hope our explanation below clearly details our decision.