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Tilehurst GP found to be at fault in care of woman



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A Tilehurst Village Surgery GP has been found to have been at fault in the care of a woman – with her family claiming it impacted on her human rights.

The GP was accused of not properly monitoring a woman’s weight loss by the family who claimed it was ‘distressing to watch her suffer.’

The complaint was brought to the Local Government Ombudsman by the woman’s daughter, saying both the council and the GP failed to safeguard and support her mother (Mrs Y).

An ombudsman has found a GP did not properly monitor a patient's weight but said their actions did not cause her death
An ombudsman has found a GP did not properly monitor a patient's weight but said their actions did not cause her death

The ombudsman was told that the woman’s family raised concerns about her weight loss to the GP, but that blood tests did not show any evidence of malnutrition.

West Berkshire Council was also accused of not safeguarding the woman. It had opened a safeguarding enquiry and assigned a social worker to the case.

The community matron service discharged Mrs Y and left it for the GP to decide to refer Mrs Y to a dietician.

Instead, the GP decided to monitor Mrs Y’s weight rather than provide nutritional support and failed to follow up with the community matron.

Later the same month, the social worker spoke to the GP. The GP said Mrs Y was not malnourished, and her weight loss was not significant to cause concern.

A week later, the GP visited Mrs Y at home. The GP said Mrs Y seemed comfortable and there was no evidence Mrs Y’s husband mistreated or starved her.

The GP did not document that home visit in Mrs Y’s medical records.

Six months later, Mrs Y had a stroke. After a month in hospital her weight had dropped further.

Mrs X (the daughter) asked the GP to carry out a home visit. The surgery tried to return Mrs X’s call but could not get through to her.

A few days later Mrs Y went into hospital and died.

In response to Mrs X’s complaint, the surgery said the GP would not have done anything differently for Mrs Y. The GP, community matron service and social worker did not have any concerns about Mrs Y’s weight.

While the council satisfied the ombudsman that it carried out its safeguarding investigation properly, it ruled that the GP did not properly monitor the woman’s weight, but agreed that their actions did not cause Mrs Y’s death, nor impacted on her human rights.

It ruled that the fault of not following up after the community matron’s visit caused Mrs X uncertainty. The GP recognised the fault and has apologised for it, as well as tightened up procedures.

The ombudsman said the GP had appropriately remedied the injustice to Mrs X and potentially others and it would not be taking any further action.



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