Mrs G’s story - Care and Compassion

Case studies

Mr & Mrs J's story

Hospital staff at Ealing Hospital NHS Trust left Mr J forgotten in a waiting room, denying him the chance to be with his wife as she died.
Mr D’s story

Royal Bolton Hospital NHS Foundation Trust discharged Mr D with inadequate pain relief, leaving his family to find someone to dispense and administer morphine over a bank holiday weekend.
Mrs R's story

Mrs R’s family were concerned that she would not receive food and drink while in Southampton University Hospitals NHS Trust unless they themselves helped her to eat and drink.
Mrs Y's story

Mrs Y died from peritonitis and a perforated stomach ulcer after her GP Surgery missed opportunities to diagnose that she had an ulcer.
Mrs H’s story

When Mrs H was transferred from Heart of England NHS Foundation Trust to a care home, she arrived bruised, soaked in urine, dishevelled and wearing someone else’s clothes.
Mr C's story

Staff at Oxford Radcliffe Hospitals NHS Trust turned off Mr C’s life support, despite his family’s request that they delay doing so for a short time.
Mr W's story

Mr W’s life was put at risk when Ashford and St Peter's Hospitals NHS Foundation Trust stopped treating him and then discharged him when he was not medically fit.
Mrs G’s story

Mrs G’s doctors at her local surgery failed to review her medication after she left hospital, with serious consequences for her health.
Mr L’s story

The care and treatment that Surrey and Borders Partnership NHS Foundation Trust gave Mr L contributed to a loss of his dignity and compromised his ability to survive pneumonia.
Mrs N’s story

While doctors at Northern Lincolnshire and Goole Hospitals NHS Foundation Trust diagnosed Mrs N’s lung cancer, they neglected to address the severe pain that she was suffering.

The Story
What our investigation found
What happened next

The story

Mrs G, who was 84 years old, had played an important part in her granddaughter’s life. She had looked after her as a small child and had lived with her for almost her entire life. Her granddaughter described her grandmother as ‘an amazing lady’ who was ‘perfectly healthy’ before she suffered a fall and underwent hip surgery.

Following surgery, Mrs G was discharged to a nursing home with a prescription which included diclofenac (a non-steroidal anti-inflammatory drug — NSAID), and given a two-week supply of the discharge medications. Mrs G was described by her granddaughter as being at this time ‘very mobile … and had most of her faculties with her’. She said Mrs G was looking forward to moving out of the home to live with her.

In the meantime, following receipt of the hospital’s discharge summary, administrative staff at Mrs G’s local GP Practice added the medications, including diclofenac, to her list of repeat medications. The Practice continuously prescribed diclofenac to Mrs G for the next eleven months, without review and without an accompanying proton-pump inhibitor (which may help protect against NSAID-associated duodenal ulcers). Mrs G went to live with her granddaughter as arranged. Her granddaughter soon noticed that Mrs G was having difficulty with food and that her health was deteriorating. Things came to a head on Christmas Day, when Mrs G was ‘violently sick, was as white as a ghost, could not move and was in pain’. She was taken to hospital and underwent emergency surgery for a perforated duodenal ulcer. Sadly, she died two months later from septicaemia, acute renal failure and urinary tract infection.

Mrs G’s death caused her granddaughter ‘immense grief due to the fact that I only recently lost my mother’.

Realising that Mrs G had taken diclofenac continuously for eleven months, her granddaughter complained to the Practice about what had happened. The Practice accepted their failure to check and review Mrs G’s medication, and they also conducted a significant event review. The learning from that review was that doctors (not administrative staff) should add medication to repeat medication lists so that they can consider appropriate co-prescribing, and that they should prescribe NSAIDs in accordance with the Practice’s protocols. (The Practice’s first audit found 20 other patients taking NSAIDs without a proton-pump inhibitor, but a subsequent audit revealed that this had been rectified.)

A 22‐year‐old student doing her final year exams, still getting over the loss of her mother and grandmother, Mrs G’s granddaughter then brought her complaint to the Ombudsman. She said that although the Practice had admitted errors, they had not said why they had occurred. She wanted to know why it had taken her grandmother’s death to highlight the mistakes, and whether her death had been preventable. She said ‘I just feel let down by the system and that my Nan died to save others’.

What our investigation found

The errors in Mrs G’s case occurred partly because the Practice’s administrative staff were inappropriately involved in the processing of her medication. However, the major cause was the failure by doctors at the Practice to follow their protocols, or the professional standards relating to prescribing and reviewing medication. They issued repeat prescriptions for the entire eleven months that Mrs G received diclofenac. As a result, no consideration was given to whether Mrs G still needed diclofenac, or whether a proton-pump inhibitor should be prescribed.

The advice at that time from the British National Formulary (the standard reference book for prescribers describing drugs, dosage and contraindication) was that NSAIDs should be used with caution in elderly patients and that a proton-pump inhibitor may be considered for protection against NSAID-associated gastric and duodenal ulcers.

Mrs G’s granddaughter specifically asked whether her grandmother’s death had been avoidable. We could not say that the ulcer and the chain of events which led to her death were the consequence of the diclofenac prescription. However, the prolonged prescription, especially without a proton-pump inhibitor, put Mrs G at increased risk of developing the duodenal ulcer.

We upheld this complaint.

What happened next

The Practice apologised to Mrs G’s granddaughter for their failings.

Our report was discussed at a significant events meeting, attended by all their doctors, nurses, receptionists and clerical staff. Robust procedures were put in place for prescribing and reviewing medication, and the Practice increased awareness of the need to follow their review processes strictly and to monitor the prescription of NSAIDs. The Practice Nurse is now qualified in prescribing and conducts the medication reviews.

Commenting on our report, Mrs G’s granddaughter said that she was very happy with the outcome and pleased that her complaint ‘will hopefully make a difference to other patients’ lives’.