Care home 'missed opportunity' to call GP - inquest

Former Bucklebury parish clerk Ronald Charles Kent died in hospital from sepsis just days later.
At the two-day hearing in Newbury last Wednesday and Thursday, his family criticised the Bupa home, Bayford House in Stockcross, for perceived health care failings.
However Berkshire coroner Peter Bedford said a “missed opportunity” to get earlier medical intervention would probably not have affected the tragic outcome.
Nevertheless, the home has made changes since Mr Kent’s death.
The hearing was told Mr Kent’s family arranged for his temporary stay, beginning on June 18 last year, to give his ailing wife and carer, Sheila, a break.
His daughter, Philippa Kent, said she informed staff that her father’s previous urinary tract infection (UTI) seemed to be recurring and added: “I asked them to ensure he drank plenty of water. It’s basic health care with a UTI.”
However, home staff said Mr Kent had often declined fluids and they could not force him to drink.
The family also claimed they wanted Mr Kent’s own GP to supply the antibiotics that had proved successful in prior UTI bouts and that staff had falsely promised to arrange this.
This account was challenged by home staff, who claimed they explained straight away that it was against policy for them to contact residents’ own GPs directly and that this was a job for the home’s GP, Dr Magdy Metwali.
However Dr Metwali said staff had not communicated this request to him, either.
Mr Kent was “in good spirits” and relatively mobile upon his admission, the inquest heard.
But Miss Kent added that, when she visited last June 27, she was horrified, explaining: “He was unconscious. No one seemed to think this was serious. I insisted an ambulance was called.”
Staff testified that it was they who had called a doctor but that his arrival was delayed until the evening when a GP carried out a scheduled visit on another resident at the home.
Miss Kent also claimed that her father’s catheter was twisted, resulting in a build-up of infected urine.
Expert witness Adam Jones, a consultant urologist at the Royal Berkshire Hospital in Reading, said the antibiotic prescribed by Dr Metwali, was a “reasonable choice” and contacting Mr Kent’s own GP would not necessarily have produced a different result.
Asked if a twisted catheter tube could have resulted in a harmful build-up of urine in the specified timeframe, Mr Jones said it was “not likely but not impossible.”
Mr Jones said that, given Mr Kent’s deteriorating condition on June 26, staff should have asked a GP to review his condition then.
Mr Kent was admitted to the Royal Berkshire Hospital in Reading next day where a consultant recorded he was dehydrated and unconscious.
After being given intravenous fluids and strong antibiotics, the inquest heard, Mr Kent made a remarkable recovery. But his condition suddenly deteriorated again and he died on July 1 from sepsis due to his UTI.
Mr Bedford said there had been a delay of two days in starting Mr Kent on antibiotics but that this had not been unreasonable.
He said there had been sufficient cause for staff to have requested a GP review on June 26 but added: “Whether an earlier hospital admission would have affected the outcome, I’m dubious about. It seems to me he was dehydrated upon hospital admission but that hospital treatment appears to have resolved it. It doesn’t appear as the cause of death.
In a narrative verdict Mr Bedford said there had been a “missed opportunity” to request a GP review on June 26 and that the following day he could have been seen by a GP earlier.
But he added: “It’s not possible to conclude that earlier recognition and treatment of dehydration and sepsis would have prevented his death.”