Sutton in Ashfield: Carers missed opportunities before woman's death

The woman died after being diagnosed with sepsis and pneumonia

A care home and GP missed opportunities to help a woman who died after an unwitnessed fall, a watchdog has found.

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, Nottinghamshire.

A report by the Local Government and Social Care Ombudsman found the home did not act quickly enough when her health deteriorated.

NHS bosses have apologised for the care Mrs C received.

The ombudsman launched an investigation into Mrs C's care after her daughter complained to NHS England, the Local Democracy Reporting Service said.

In a report, it said Mrs C was first seen by a GP after a fall on 6 January, when she appeared to be having problems with her breathing.

Despite instructions to call the next day if her condition had not improved, care home staff did not contact the GP again until 10 January when her daughter raised the alarm.

But the GP did not conduct an examination, and prescribed antibiotics for an undiagnosed urinary tract infection.

Mrs C was taken to hospital on 15 January, where she was diagnosed with sepsis and pneumonia in hospital. She died on 25 January.

The report concluded both Skegby Family Medical Centre in Mansfield Road, Skegby, and Nottinghamshire County Council - which the care home was acting on behalf of - needed to issue an apology to her family.

A spokesperson for NHS Nottingham and Nottinghamshire Integrated Care Board, which organises NHS services in Nottinghamshire, said: "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."

The report says it was 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.

Discussing the report at the county council's governance and ethics committee on Wednesday, councillor Michael Payne said he thought the care would "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," he said.

Committee chairman Philip Owen said he was "appalled" when he read about the case.

Skegby Family Medical Centre is now run by a different provider - Brierley Park Medical Group - which took over last year.

The care home has also been contacted for comment.