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Case ref:202408314
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Date:August 2025
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Body:A Medical Practice in the Lanarkshire NHS Board area
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Clinical treatment / diagnosis
Summary
C complained about the care and treatment provided to their late parent (A) by a GP Practice when A was a resident in a care home. Care home staff had reported that A was agitated and unsettled, possibly in pain and with poor sleep at night. The practice requested that care home staff take a set of observations (temperature, oxygen saturation, pulse, blood pressure) and obtain a urine sample. When observations were later taken by care home staff, the practice advised that they were all normal, thereby giving a NEWS Score (a tool used to quickly determine the degree of illness of a patient and identify acute deterioration) of 0. They said that no visit was indicated at that time and queries about medication for agitation would be discussed on the next GP round to the care home. C was of the view that the report of agitation and confusion should have led to GP review.
We took independent advice from a GP. We found that the care and treatment provided to A was unreasonable, as A had delirium until proven otherwise and should have been seen and assessed for this. We also noted that the practice appear to have relied on a NEWS score to decide no visit was needed, but NEWS is not validated for use in primary care. We therefore upheld the complaint.
During the course of our investigation the practice carried out a Significant Event Review. As a result, they had developed a protocol, to be used alongside physiological measurements, for assessing delirium in the care home setting and had shared and discussed this with the care home. We considered these actions to reasonably address the failings in this case, so aside from apologising to C, we made no further learning and improvement recommendations.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for failing to assess A for delirium. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/meaningful-apologies" www.spso.org.uk/meaningful-apologies .