Summary of Primary Care Learning for SAR BB

This case has been extensively reviewed as part of a SAR (Safeguarding Adult Review) and multi-agency learning has been documented and disseminated. The full report is published on the NSAB website.  As lead GP for Adult Safeguarding CCG for Norfolk & Waveney, I have summarised the case with particular reference to primary care.

Mrs BB was an 84yr old woman diagnosed with dementia from 2012. She lived alone after her husband was placed in residential care nearby in 2013. There were concerns about her safety due to her becoming lost, sometimes approaching strangers for help or lifts home.

In November 2014 a mental capacity act assessment was carried out on her ability to make decisions about where she received care and support. This resulted in a best interests decision which recommended a residential placement near one of the family members. Unfortunately the result of this assessment and best interests decision was not shared with GP practice.

While these arrangements were being made, the homecare support was increased, but on occasion Mrs BB went out during the night, putting herself at risk. On the evening of 19.01.15 she walked to her husband's care home and was agitated and aggressive. The care home called the police and the situation was defused and her son agreed to take her home. The following day, her behaviour was still agitated and aggressive so the care worker supporting Mrs BB during the day, was concerned. He made an appointment for Mrs BB to see a GP that evening. The GP advised that he was not made aware of the need for police intervention the previous evening and he did not include a reference to Mrs BB's capacity in his medical notes.

The GP decided that Mrs BB should be taken to A&E where she would be in a place of safety and further investigations could be carried out. He handed the carer a sealed envelope with his assessment inside to give to the hospital. However, the care worker subsequently advised that he did not realise that the GP had wanted Mrs BB to be in a place of safety that evening so that she would not be left alone.

On leaving the surgery, the carer advised that Mrs BB refused to go to hospital with him, so after discussion with his manager, the carer returned her home and settled her for the evening. He advised that he waited outside her house for 15 minutes before leaving to make sure that she had settled with a plan to take her to the hospital the next morning.

Unfortunately, during the night, Mrs BB left her home and was found the next day deceased, having fallen into a ditch just beyond her husband’s care home.

Correct Coding of Dementia Diagnoses

Mrs BB received a formal diagnosis of dementia after a review by the Memory Team on 6 September 2012; this was coded in her notes as "unspecified dementia" which unfortunately was not recognised as a "QOF domain". This meant that her notes did not flag her as a "dementia patient" so she was not automatically added to the register of dementia patients. As a consequence, the practice was not prompted to arrange her annual dementia review in May 2014, she was not considered at an increased risk of hospital admission and the practice was not prompted to confirm family contact details as there was no "QOF dementia alert".

Please can you check your patient's records and make sure that all patients with a dementia diagnosis are correctly coded and flagged. They should be included in the register of dementia patients and arrangements should be made for them to have appropriate medical reviews.

Making sure that up to date family/carer contact details are recorded

On several occasions, the practice sent letters directly to Mrs BB advising of missed appointments. A copy was not sent to a family member so it is not known if Mrs BB knowingly ignored these letters or forgot them. When a patient with dementia lives alone, or with a family carer who is also incapacitated, please consider obtaining consent or making a best interests decision to send practice communications to a recognised carer/family member.

Please check that all patients on your dementia register have up to date carer/family contact details including addresses for correspondence if the patient lives alone or with an infirm family member/carer.

Documenting mental capacity

There was no documented assessment of Mrs BB' s capacity in her final consultation. However, a "best interests decision" was implied by the fact that the GP allowed the care-worker to prevent her from leaving the consultation room. In the future, it will be increasingly difficult to defend a "best interests decision" if there is no accompanying documentation of the patient's capacity.
Please consider checking if there is a mental capacity assessment tool within your IT system which you can access to facilitate this and remind yourself of the procedure. A full capacity assessment may not be feasible in a 10 minute consultation, but documentation of a reference to their capacity may justify a "best interests decision".

Dr Pippa Harrold
Lead GP Adult Safeguarding Norfolk & Waveney CCGs

GP Consultations which include a care worker and the patient

It is not unusual for a patient to attend GP consultations with a care worker. The care worker often ushers in or follows the patient into the surgery. It is not immediately apparent in what capacity they are attending. Consent for their presence is often implied as the patient does not appear to object to their presence. How often do we challenge their presence? Do you routinely ask who they are? In this case, Mrs BB had had a formal assessment of her mental capacity and she was waiting for a best interests decision to be implemented in which she would be moved into a Residential Care Home which was acceptable to her family. An increased care package of a one-to-one from 08.00 to 18.00 had been put in place to "keep her safe" in the meantime. The carer in this case had already made a best interests decision to book the GP appointment as her behaviour had become increasingly agitated and he had used subterfuge to drive the patient to the surgery. The GP recognised that Mrs BB may have had a toxic confusion state but was not able to test her urine or access urgent blood tests to confirm. He therefore advised that she should be taken "to A&E" for further investigations and documented in a sealed document "Carer will take to AE as a place of safety for assessment / will contact A”. The carer did not remember this term being used and thought that Mrs BB needed further investigations and as an ambulance was not requested, he did not realise that the GP had expected him to take her and that he had agreed to take Mrs BB to A&E that evening.