Case No. E.2211/97-98

Full text of selected cases                    

Case No. E.2211/97-98

Treatment by a doctor from a deputising service; complaint handling by the deputising service; insufficient assessment and monitoring by nursing and medical staff, and inadequate care

Complaint as put by Mr X

1. The account of the complaint provided by Mr X was that on 28 June 1996 his son, Master X, was prescribed Amoxil (an antibiotic) and paracetamol by a general practitioner (GP) because he was ill with a high temperature after returning from a holiday abroad. On 3 July the child was no better, and he was visited by a doctor (the deputy) from the deputising service which was used by Mr X's GP to deal with calls out of surgery hours. (The deputising service acts as an agent to provide deputies to cover out-of-hours services for GPs, and has managerial responsibility for ensuring that those deputies provide a satisfactory service.) Mr X's daughter explained to the deputy that Master X might have malaria because he had been to Pakistan; but the deputy dismissed that suggestion, saying that Master X did not show any symptoms of the disease. The deputy concluded that Master X had had an adverse reaction to Amoxil, and said that this should be discontinued. He gave no advice about what to do if Master X's condition deteriorated. The following day Mr X's GP sent Master X to hospital, where he was diagnosed as having malaria. 

2. Mr X complained on 5 July to Birmingham Health Authority (the HA), who passed his complaint to the deputising service on 9 September. On 11 September the medical director of the deputising service (the medical director) wrote to the HA apologising to Mr X for any undue distress caused by the deputy's visit on 3 July, and explaining that he had returned to Africa. Mr X wrote again to the HA on 26 October asserting that the investigation of his complaint should not cease because the deputy had gone abroad. The medical director replied on 5 November; and on 6 May 1997 Mr X had a meeting with the medical director and the general manager of the deputising service. On 11 December 1997 the HA's convener refused a request by Mr X for an independent review. Mr X remained dissatisfied. 

3. The matters subject to investigation were: 

(a) that the deputy 

(i) did not take proper account of Master X's symptoms and recent visit to a malarial area;

(ii)made an inappropriate diagnosis; and

(iii)did not give advice to Master X's parents about what to do if his condition deteriorated; and

(b)that the deputising service's handling of Mr X's complaint was inadequate in that the deputy was not asked for his substantive response to the complaint.

Investigation

4. My investigator took evidence from Mr X and his daughter, the deputy, and the medical director. I appointed two independent professional assessors to provide me with clinical advice: their report is reproduced at paragraph 16. 

Policy guidance

5. At the time of the events complained about, a Department of Health Circular HC(FP)(84)2 applied. It stated that responsibility for ensuring that deputising services were of a satisfactory standard, and for monitoring the standards of deputising services, lay with the health authority, or the family health services authority (FHSA). On 1 October 1993 Birmingham FHSA produced a document to regulate the operation and use of deputising services within the city of Birmingham. This stated: 

'Out of hours care in general medical practice, however it is provided, should be of no less [a] standard than that provided in hours. Good quality, well run deputising services are one acceptable way of providing doctors with the necessary relief from duty. The aim is to ensure that patients receive a satisfactory service at all times .... .

'....

'The Service shall make satisfactory arrangements for the continuity of care and follow up of cases seen by the Service by:-

(a) The Deputy handing a written report to the patient in a sealed envelope for delivery to the patient's doctor ....'

Clinical guidance

6. In 1995 the Department of Health issued guidance for GPs entitled 'Health Information for Overseas Travel', which states: 

'About 7 people die from malaria each year in England and Wales and almost all these deaths are preventable .... Most deaths from malaria have followed delay in diagnosis because neither the returned traveller nor the doctor took prompt medical action for illness and/or fever ....

'.... Early and rapid diagnosis is necessary to reduce complications and [risk of] death. .... fever is the most common [symptom], but the symptoms are usually non-specific and include flu-like illness, backache, diarrhoea and joint pains .... The urgency to make the diagnosis cannot be over-emphasised ....'

7. In September 1997 the Public Health Laboratory Service (PHLS) issued a report, which was distributed by the Department of Health to all GP surgeries, entitled 'Communicable Disease Report' and which states: 

'[Falciparum malaria] is the only one of the four species of malaria parasite that poses a substantial risk of .... death .... [but] the other species [including vivax malaria] can also make people very ill.

Under the heading 'South Asia' (which includes Pakistan) it states: 

'[Vivax malaria] predominates, but [falciparum malaria] is also present and often resistant to chloroquine [a prophylaxis]; mixed infections occur. ....'

(Note: Prophylaxis is medication given to a patient to protect from or prevent disease.) 

Complaint (a) that the deputy (i) did not take proper account of Master X's symptoms and recent visit to a malarial area; (ii) made an inappropriate diagnosis; and (iii) did not give advice about what to do if Master X's condition deteriorated 

Complainant's evidence

8. Mr X told my investigator that he could not remember if he mentioned the possibility of malaria to the GP who visited Master X on 28 June 1996. At that time Mr X thought Master X had an infection; he did not suspect malaria. A few days after that visit, Master X's symptoms seemed to be getting worse, particularly towards evening time; and Mr X began to think that Master X's high temperature could be due to malaria, in view of his recent visit to Pakistan. Master X had not had any prophylactic medication. On the evening of 3 July Mr X was working; his daughter, who was thirteen at the time, was asked to call out a doctor, because Mrs X speaks no English. 

9. Mr X's daughter, Miss X, confirmed that when she telephoned the deputising service she explained that Master X had been vomiting, had stomach pain and a high temperature, and that he might have malaria. When the deputy visited, she gave him the same information, and repeated her father's concern that Master X could have malaria as he had recently been to Pakistan. The deputy listened to what she said, took Master X's temperature, and then told her that as he lived in Africa he knew very well how a person suffering from malaria would look; also that just because someone had a high temperature that did not mean they had the disease. Miss X recalled the deputy saying that if Master X was well enough to watch television he could not have malaria. He advised that the Amoxil should be stopped because he thought Master X had had an adverse reaction to it, and he left a letter with the family to give to their own GP. 

10. Mr X said that the letter left with the family was a copy of the deputising service's call-out form (which I have seen) and that the deputy left no instructions about what they should do if Master X did not get better. The following day he called out the family's GP, who suspected malaria and arranged for Master X to be admitted to hospital immediately. There he was diagnosed as having malaria, which was later shown to be vivax malaria, and he was started on medication immediately. Mr X, who is a paramedic, said that he would not have requested a home visit unnecessarily. He was upset that the deputy had not been alerted by Master X's symptoms and had not sent him to hospital. 

Evidence of the deputy and the deputising service                    

11. The deputy confirmed that the information given to him about Master X included that he had been to Pakistan without prophylaxis. In a patient with malaria, he would expect to see profuse sweating, a temperature of over 40 degrees, possibly a swollen spleen, possibly diarrhoea, and anaemia. On examination he found that Master X did not have a high temperature and did not have an enlarged liver or spleen. He was lying down watching television; and from the deputy's own experience of having malaria he thought that if Master X had had malaria he would not have felt well enough to do that. He did not seem to have diarrhoea (he had not had a bowel movement for more than four hours), or the more generalised gastric symptoms associated with malaria. The deputy said that to confirm a diagnosis of malaria a blood test was necessary. However, the test was not always reliable, because the parasite which caused the disease left the liver to be present in the blood only during an episode of high temperature. If Master X had had a high temperature he would have referred him to the infectious diseases unit at Birmingham Heartlands Hospital. There was now a more refined test, not available in 1996, and said to be fully reliable, although he was not totally convinced of that. 

12. The deputy thought that a GP practising in the United Kingdom (UK) would know that the type of malaria found in Africa (falciparum malaria) could result in the death of the patient, while '99%' of strains of the disease found in Pakistan, including vivax malaria, were not life-threatening. He would regard the practice of sending all patients presenting with Master X's symptoms and history to hospital as 'erring on the side of caution'. He said that the local community covered by the deputising service was largely Asian; and he saw a great many patients with a high temperature who had returned to the UK from Pakistan. He could not send every patient with such presenting symptoms to the infectious diseases unit; it would not be viable. 

13. The deputy said that he considered Master X's epigastric symptoms (Note: these are symptoms which are experienced in the abdomen just below the breastbone) showed a gastric sensitivity to Amoxil. He said that vomiting was a common side-effect of Amoxil. The deputy said he routinely told a patient to visit his or her own GP if things did not improve. He thought he would have given this advice to the family, but he could not remember specifically what he had told them. He would have expected Master X's symptoms of reaction to the Amoxil to have disappeared within 24 hours, so if they had not, it would have been necessary for the family to contact their GP. 

14. The medical director said that all doctors recruited to the deputising service had to provide, amongst other things, evidence of their Joint Committee vocational training (Note: that is, training which since 1995 all GPs must have if they are going to practise in the UK). The deputy had not had that vocational training because he qualified in Africa, and so the Quality Assurance Group of the then Birmingham FHSA interviewed him before approving his application to work for the deputising service (Note: I have seen a letter following his interview in June 1993 which confirms that the FHSA approved his application to work as a deputy doctor.) The medical director said that deputies were responsible for their own actions, but it was the deputising service's responsibility to see that they were adequately trained. He ran postgraduate courses for a week twice every year which his deputies were encouraged to attend. The deputy had attended once every year since his appointment. 

15. The medical director said that he would not routinely refer patients to hospital for admission or for out-of-hours blood tests because of a recent visit to a malarial area; it would depend on the patient's clinical condition. If necessary, he would order blood tests to be done the following day, usually through the patient's GP; he did not think that a hospital would ask a technician to attend the hospital at night to do a blood test. The medical director did not think that the deputy should have arranged for Master X to have blood tests straight away; at the time of the deputy's visit there was no indication to do so. He thought it was reasonable for the deputy to suggest that the patient should see his GP the next day. The medical director did not advise his deputies on the diagnosis and treatment of malaria. 

Professional assessors' report                    

16. I reproduce next, in its entirety, the report prepared by the professional assessors I appointed to advise me about this complaint. 

Report by the Professional Assessors to the Health Service Ombudsman for England of the clinical judgments of staff involved in the complaint made by Mr X:

Professional Assessors:

BASIS OF OUR REPORT

In formulating our report we have perused the following documents made available to us by the Health Service Ombudsman which have included:

1. The letter of complaint by Mr X—5 May 1996.

2. The letter from the deputy chief officer of East Birmingham Community Health Council—11 June 1997.

3. The deputising service's call note—3 July 1996.

4. Hospital discharge note—6 July 1996.

5. Investigating officer's interview notes—Mr X— 27 July 1998.

6. Investigating officer's interview notes—the deputy —10 August 1998.

7. Investigating officer's interview notes—the medical director—30 September 1998.

We have not interviewed any of the parties in this matter and have based our conclusions on the information gained from the perusal of the above documents and we have confined our comments to specific matters to which our attention has been drawn by the Office of the Health Service Ombudsman.

Introduction

In this matter we are asked by the Health Service Ombudsman for an opinion on whether:

1. The deputy took proper account of Master X's symptoms and his recent visit to a malarial area.

In this area we have sought guidance from Birmingham Heartlands Hospital's Department of Infection and Tropical Medicine, which is the local unit for the area where Master X lives. The unit issues a sheet to all Birmingham GPs showing what chemoprophylaxis is necessary for patients travelling to the various malarial areas. The unit does not advise admission to hospital for cases of known vivax malaria if the patient is well and the case is uncomplicated; but two blood films are necessary to detect the strain of malaria. All cases of known falciparum malaria are to be admitted. We are further advised that the unit can, on request, carry out such blood tests 24 hours a day.

Most GPs in the United Kingdom have little experience of dealing with malaria. It is a GP's role, therefore, to ascertain the possibility of malaria and thereafter refer the patient to the appropriate unit with expertise to carry out the diagnostic blood tests and for appropriate management. The illness may not always be diagnosed in the first blood film and therefore follow-up by the same unit may be required.

The deputy visited the patient on behalf of the deputising service. He took an appropriate history and made an appropriate examination of the patient. The deputy knew that the patient had been to Pakistan to visit recently and he was also informed and was aware that during Master X's time in Pakistan he did not take the usual precautions against malaria.

The deputy gained his clinical experience in Africa, where he dealt with malaria extensively. He believed that if Master X had been to Pakistan, the type of malaria he might have contracted would be different from that contracted in Africa and would not be life-threatening. That determined the actions he took with Master X, namely that, in the absence of a high temperature and other acute symptoms of malaria, he ignored the possibility of Master X having malaria and diagnosed an antibiotic-induced gastritis in view of Master X's epigastric symptoms. Such action does not take into account the fact that the consequences of vivax malaria can be considerable and that the illness needs firm action.

We consider that if the deputy believed that Master X did not show the signs of malaria on this occasion he should still have been alerted to the possibility of recurrence. In the United Kingdom a non-life threatening disease such as vivax malaria is able to be treated by the NHS, whether that be through admission to hospital or as an outpatient. It is our view that it would have been appropriate in the circumstances for the deputy to refer Master X to hospital immediately for a blood test.

2. The deputy made an inappropriate diagnosis

At the time of the deputy's visit he examined the patient properly and reported that the patient did not have a high temperature which made him decide against malaria as the cause of the problem. He diagnosed antibiotic-induced gastritis in view of Master X's previous prescription for Amoxil and his presenting gastric symptoms. As the earlier symptoms of upper respiratory tract infection, for which the antibiotic had been prescribed, appeared to have cleared up, the deputy said that Master X should stop taking the antibiotics.

It is true that Amoxil can cause gastric upset; and, without any other history, such a diagnosis would be appropriate. However, bearing in mind the reported history and symptoms, this diagnosis appears to ignore the indication that Master X might have malaria.

3. The deputy did not give advice to Master X's parents about what to do if his condition deteriorated

Miss X said that at the conclusion of his visit the deputy left a letter (a copy of the call-out form on which the deputy had made his clinical notes) with the family to give to their own GP, but that he left no instructions about what they should do if Master X did not get better. The deputy said that he could not remember the visit but that he routinely told patients to visit their own GP if things did not improve. From the way in which the deputy conducted the consultation we consider it likely that he would have advised the patient's family to contact their own GP if the symptoms persisted. However, he does not appear to have entertained the idea that his diagnosis could be wrong, and accordingly appears not to have given the family any advice about what to expect, what symptoms to look for, nor how to deal with the situation.

Findings (a) (i)

17. Master X had been ill for some days when the deputy was called on 3 July 1996. By that time Mr X suspected that Master X might have malaria: Mr X's daughter said so to the deputy. The deputy concluded that Master X did not have the symptoms he would have expected if the boy was suffering from malaria. He told my investigator that the symptoms he would expect were profuse sweating, a temperature of over 40 degrees, possibly a swollen spleen, possibly diarrhoea, and anaemia. The Department of Health guidance, however, (paragraph 6) points out that while fever is common, symptoms are usually non-specific and include flu-like illness, backache, diarrhoea and joint pains. The deputy also told my investigator that, in any case, '99%' of the strains of malaria found in Pakistan were not life-threatening and that he could not send all patients with a high temperature who had recently returned from Pakistan to the infectious diseases unit. 

18. I am advised by my assessors that patients with suspected malaria should be referred for diagnostic blood tests which will show whether a patient has malaria and, if so, which strain of malaria is present. The assessors say that even though the deputy considered that Master X did not show signs of the disease on examination, he should have considered the possibility of recurrence, and referred Master X for blood tests. This diagnostic action seems to me appropriate in view of the Department of Health and PHLS guidance (paragraphs 6 and 7) which states that 'early and rapid diagnosis is necessary to reduce complications and [risk of] death'. The guidance also says that falciparum malaria, which is life-threatening, can be found in Pakistan, and that, while vivax malaria is not life-threatening, the consequences of the disease can be very serious. My assessors have confirmed (paragraph 16) that the haematology department at Birmingham Heartlands Hospital can be asked to carry out diagnostic blood tests in cases of suspected malaria at any time of the day or night. I am concerned that the medical director considered the deputy's actions were correct in not referring Master X for blood tests. I consider that the deputy did not take proper account of Master X's reported symptoms and recent history of a visit to a malarial area, and that he should have referred him to hospital for a blood test that night. I acknowledge that the deputy gained his experience of general practice in Africa, where malaria is endemic and where the more serious form of the disease (falciparum malaria) is found. I acknowledge, too, that he had considerable knowledge of, and experience in managing the disease—indeed he had suffered from it himself. However, in this case the deputy was under an obligation to follow Department of Health guidance and to apply the standards implied by that guidance, which Master X and his family had a right to expect. He did not do so. I uphold the complaint. 

Findings (a) (ii)

19. Mr X complained that the deputy made an inappropriate diagnosis. In view of Master X's previous prescription for Amoxil and his presenting epigastric symptoms, the deputy made a diagnosis of antibiotic-induced gastritis. My assessors have said that the antibiotic could have caused gastric upset and that, without any other history, such a diagnosis would have been appropriate. They conclude, however, that in the light of Master X's reported symptoms and past medical history it was wrong for the deputy to ignore the possibility of malaria. I agree with that view; and I uphold the complaint. 

Findings (a) (iii)

20. Mr X's daughter said that the deputy gave no instructions to the family about what to do if Master X's condition deteriorated. The deputy could not remember the circumstances of the visit, but said that it was his usual practice to advise patients to see their own GP the morning after his visit if they remained worried. The medical director said that that would be normal practice for a deputy, and my assessors have concluded that it was likely that he would have done so. I note that he provided a letter, as required of him (paragraph 5), to be given to the family GP which handed back Master X's care. As a result, I find it unlikely that the deputy would have done that, without also saying that the family should see their GP if they remained worried. However, my assessors have also concluded that the deputy did not appear to have entertained the possibility that his diagnosis could be wrong, and did not therefore give the family any advice about what to expect, what symptoms to look for or how to deal with the situation. To the extent that that was not done, I uphold the complaint. 

Complaint (b) the handling of Mr X's complaint was inadequate

Chronology

21. I set out below the main events and correspondence relevant to Mr X's complaint. 

1996 

3 July—the deputy visited Master X at home.

5 July—Mr X wrote to the HA complaining about the deputy's actions.

His letter included:

'On Wednesday July 3rd a locum doctor came out to see [Master X] who had been ill for nearly a week. He was seen previously by a locum on Friday 28th June who prescribed Disprol and Amoxil. The child was suffering from pyrexia [high temperature] of unknown origin after having been on holiday abroad to Pakistan for two months. All this was explained to the doctor who came out on July 3rd.

'[The deputy] made no attempt to check the patient to diagnose, in fact he stopped the medicine he was taking and made some unnecessary comments ....

'Because the television was on, the child who was lying on the settee and happened to be looking in that direction, the doctor stated that he was alright because he was watching the television.

'It was suggested to him that he may have malaria but he refused to accept that and said that he had seen many patients in the past with malaria and that the child was not suffering from it.'

10 July—the HA acknowledged Mr X's letter of complaint, and advised him that his complaint should be dealt with by the deputising service. They asked Mr X to contact them if he wished them to pass the letter to the deputising service.

(Note: Due to a misunderstanding the letter was not passed to the deputising service at that time (see paragraph 23).)

9 September—the HA passed Mr X's letter to the deputising service.

11 September—the medical director sent a letter to the HA in reply to Mr X's complaint, in which he said:

'Please would you extend my sincere apologies to [Mr X] for any undue distress caused to [Master X] or the family on 3 July, and I trust that [Master X] is now in good health and has made a full recovery.

'Unfortunately the [deputy] concerned has returned to .... Africa and no longer works for this service.'

26 October—Mr X was not satisfied with this reply, and wrote again to the HA asking them to investigate. He said that he held the deputising service responsible for the deputy's actions, and that the investigation should not cease because the deputy had left the country.

30 October—the HA passed Mr X's letter to the deputising service for their reply.

5 November—the medical director replied to the HA and said:

'I am enclosing all the reports regarding the visit to [Master X]. These include .... [the deputy's] report.

'In relation to [the deputy], he was approved to work for this [deputising service] on 30th June 1993. Since then he has worked for about 6 months each year for this service. During this period of time his standard of work has been of the highest order and as far as I am aware, there have never been any previous complaints regarding his treatment of patients.'

The letter included details of the deputy's qualifications, and concluded with further apologies for any distress caused to Mr X and his family.

18 December—the East Birmingham Community Health Council (the CHC) requested, on Mr X's behalf, an independent review of his complaint.

1997

21 March—the convener for the HA decided to refer Mr X's complaint back for further local resolution by the deputising service. The convener suggested that Mr X should be offered a meeting with the medical director.

6 May—a meeting took place between Mr X, the medical director, a CHC representative and a conciliator.

17 July—following the meeting, the CHC, on Mr X's behalf, again requested an independent review. That letter repeated Mr X's complaints about the deputy and included:

'.... [Mr X] believes that the excuse given that blood tests to detect malaria can only be done at certain times is incorrect. He believes that if it is necessary to do a blood test at any time of the day, it is possible, at the nearest hospital, Birmingham Heartlands Hospital. [Mr X] believes it is essential that a blood test is carried out for pyrexia of unknown origin to identify cause and eliminate danger.'

The letter also stated:

'.... [Mr X believes that] a doctor who leaves the country to work abroad should be accountable.'

11 December—the HA convener rejected Mr X's request.

The deputising service's complaints procedure

22. The deputising service did not have a formal complaints procedure at the time of the events complained about. Their current complaints procedure dated May 1998 states: 

'When we investigate your complaint, we shall aim to:-

'find out what happened and what went wrong

'make it possible for you to discuss the problems with those people directly involved, if appropriate

'make sure that you receive an apology, where appropriate

'identify what we can do to make sure that the problem does not arise again.'

Complainant's evidence

23. Mr X said that after he made his complaint through the HA, there was a delay because the HA thought, mistakenly, that he had not given permission for them to pass his complaint to the deputising service for a response. The HA then forwarded to him copies of the medical director's replies to the complaint; he did not get a reply directly from the deputy. A meeting was held on 6 May 1997 at which the medical director apologised for what had happened, but none of the substantive issues was addressed. They discussed Mr X's concerns that the deputy had not ordered a blood test for Master X on the night of 3 July. The medical director told him that blood tests could not be carried out at night at Birmingham Heartlands Hospital. He was disappointed because he had hoped to be reassured that the deputy's mistake in not ordering a blood test would not be repeated. Also, he could not understand why the deputising service did not know where the deputy had gone.

The deputising service

24. The medical director said that he always dealt with clinical complaints himself. He depended on the comments of his deputies to respond to a complainant about what had happened. In this case he did not have the deputy's address or telephone number and so could not contact him. My investigator showed the medical director a copy of a letter from the deputising service's own files, which gave an address in Africa for the deputy. The medical director acknowledged that he had not noticed that it was on the file, although he pointed out that the address could have been out of date as the letter was written in 1991. He said that the deputising service did not usually keep forwarding addresses for deputies, as they had a high turnover of staff. He said that if he had been able to speak to the deputy about this complaint it might have resolved the matter. My investigator told the medical director that she had contacted the deputy by obtaining his current address from the GMC. The medical director said that in future he would go through a deputy's file himself to see if there was any way of contacting him or her. 

25. The medical director said that his letters of 11 September and 5 November 1996 had not been addressed to Mr X because he had responded to the person at the HA who had written to him. He considered that his letters might not have answered Mr X's complaint adequately, but that adequate answers had been given at the meeting on 6 May 1997. At that meeting Mr X had stated his concerns, and the medical director had answered them. He had put across his own views about malaria based on his experience. He explained at the meeting that he thought the deputy's actions had been appropriate. Mr X would not accept the answers he had given, and disagreed with him about whether a blood test could be ordered at any time. He thought it might have helped if he had met Mr X earlier, but he did not think Mr X would ever have been satisfied. 

Findings (b)

26. Mr X complained about the handling of his complaint, especially that no response was obtained from the deputy. The medical director has acknowledged that had he contacted the deputy about the complaint it might have resolved the matter. He thought that he could not obtain the deputy's comments because he did not have an address for him in Africa. However, as my office has shown, there were ways in which he could have obtained the deputy's address; I am pleased to note that he will seek personally to obtain an address in any similar circumstances in future. The medical director has said that his letters of 11 September and 5 November 1997 may not have adequately answered Mr X's complaint, and I agree. He thought that the meeting with Mr X had provided adequate answers, but that Mr X would never be satisfied. At that meeting a disagreement developed over whether or not a blood test could be obtained from Birmingham Heartlands Hospital at night. I am advised (paragraph 16) that a blood test could have been obtained. The disagreement might have been resolved if that information, even if not available at the meeting, had been made available afterwards. I consider that the medical director's response to Mr X was generally poor, and that with some effort a response could have been obtained from the deputy. I recommend that in future the deputising service should keep a record of forwarding addresses. I uphold the complaint. 

Conclusion

27. I have set out my findings in paragraphs 17, 18, 19, 20 and 26. I have upheld all three clinical aspects of Mr X's complaint about the actions of the deputy (the third to a limited extent), as set out in paragraph 3(a) above. I have concluded that on the occasion of the deputy's visit to Mr X's home, the service provided by the deputising service was unsatisfactory and not in accordance with the FHSA regulations governing its operation at that time. The deputising service have agreed to implement my recommendation in paragraph 26 and have asked me to convey to Mr X—as I do—their apologies for the shortcomings I have identified.