A care home and GP missed opportunities to help a woman who died just weeks later, a watchdog has found.
Councillors have also raised fears the lack of proper care wasn’t an isolated incident.
The woman, named only as Mrs C, died in January 2022 after contracting sepsis and pneumonia at Sutton Court Care Home in Sutton-in-Ashfield.
A report by the Local Government & Social Care Ombudsman, which reviews complaints into authorities, found that home didn’t act quickly enough when her health deteriorated.
A GP at the Skegby Family Medical Practice on Mansfield Road, Skegby, also didn’t properly examine her and incorrectly treated her, it said.
Mrs C was first seen by a GP after a fall on January 6, when she appeared to be having problems with her breathing.
Despite instructions to call the next day if her condition hadn’t improved, care home staff didn’t contact the GP again until January 10 when her daughter raised the alarm.
But the GP didn’t conduct an examination, and prescribed antibiotics for a urinary tract infection despite there being no evidence for this.
The Ombudsman found this fell below the standards required by the General Medical Council.
Mrs C was then hospitalised on January 15, when a staff member said she appeared “quite grey/yellow” and “generally unwell” with shallow breathing.
She was diagnosed with sepsis and pneumonia in hospital, and passed away on January 25.
The report says it is impossible to know whether better help would have saved the woman’s life, but said both parties fell short of the required standards of care.
The care home also failed to inform Mrs C’s daughter that she had fallen on two occasions, contrary to the Care Quality Commission’s requirements.
The Ombudsman told both the medical practice and Nottinghamshire County Council – who the care home was acting on behalf of in care – to issue an apology to Mrs C’s family.
The council says that the care home now has better measures to recognise patient deterioration.
Sutton Court Care Home, on Priestsic Road, is run by Ashmere Nottinghamshire Ltd and is currently rated ‘Good’ by inspectors at the Care Quality Commission.
The report, which was published in November, was discussed at the council’s Governance and Ethics Committee on Wednesday (January 10), where members expressed concern.
Councillor Michael Payne (Lab) said: “This will not be an isolated incident.”
“I think it is absolutely shocking that we can have a medical practice or a care home who aren’t willing to properly respond to what clearly here is a deeply egregious situation where this poor individual has lost their life.
“It demonstrates that the council is unable to outsource accountability.
“We’ve got a private care system here that allows a situation where the council is completely powerless to compel these people to take action, but we are ultimately responsible.
“I’m really worried about that.”
Committee Chairman Councillor Philip Owen (Con) said: “I was appalled when I read this case.
“What appals me even more is the GP that failed to attend to this poor lady who subsequently died, and to add insult to injury, didn’t respond to the failings that have been highlighted by the NHS.
“This sort of behaviour smacks of the Post Office, doesn’t it? Which is totally acceptable.”
Skegby Family Medical Practice is now run by a different provider – Brierly Park Medical Group – which took over running services last year.
A spokesperson for NHS Nottingham and Nottinghamshire ICB, which commissions NHS primary care services in Nottinghamshire said: “We are sorry that the standard of GP care was not what it should have been in this case and support the Ombudsman’s findings.
“Since this incident, significant changes have been made at Skegby Family Medical Centre, including new management of the practice following a merger with Brierley Park Medical Centre in 2023. The GP referred to in the ombudsman’s report is no longer employed at the practice.”
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