Special Report: How a Banbury surgery failed a dying woman

The report was about a businesswoman who is now receiving specialist treatment for lymphoma but only after months of delay because of management decisions at Horsefair Surgery, Banbury.

Her account prompted scores of complaints about the surgery – which was contracted to a private company in 2016 after the last three GPs left in frustration over the pressures put on the system.

The company – IMH Ltd – lost its contract last August. It has been taken over by PML Ltd which runs Banbury’s first primary care network.

Patients’ complaints about Horsefair have raged since it was first contracted out. They said they could not get through on the phone, endured long waits for appointments, had problems getting prescriptions, were not assigned to an individual GP and rarely saw the same GP twice.

Locums were employed for short-term work and were not from Banbury. The stories the Banbury Guardian has heard include numerous cases of minor ailments being dismissed but ending up being terminal cancer. Most, but not all, were Horsefair patients.

Grieving relatives described the deaths of their loved ones – as young as 32 – because their complaints had not been investigated.

After the publication of our story, the Banbury Guardian newsdesk received some distressing emails. One woman’s father, in his 60s,had had more than 18 appointments with Horsefair without his cancer in the lungs and other organs being detected. Doctors at the Horton’s A&E quickly admitted him and discovered the disease but he died within three weeks.

No story was as distressing as that of a Banbury area woman who has complained that her mother’s harrowing death from lung cancer was mismanaged by Horsefair.

The woman said her mother’s diagnosis had been delayed in part because Horsefair had notices forbidding patients from discussing more than one ailment per visit.

“In the last five months I had been looking after mother at home as she wished and was getting only two or three hours’ sleep a night.

“One night she was struggling to breathe and I thought she was going to die. She thought the same and my daughter and I said our goodbyes. I called Katharine House Hospice who were brilliant and came as soon as possible.

“Mother sounded as though she was drowning. I could see the fear in her eyes. She was begging to die.”

The next day Horsefair approved a pump driver to administer medication but the drugs and the paper work the district nurse needed to administer it were not there.

“She spent an hour on the phone to the surgery trying to get this in place,” the woman said. “My sister-in-law went to collect them so the nurse could keep topping up approved medication at home.

“But the meds weren’t available and no-one seemed to know anything about my mother. My sister-in-law told them she would not leave without the medication and was finally given the drugs.

“But when she got back, the directive to administer the drugs wasn’t there. After 30 to 40 minutes more on the phone, Horsefair said they would leave it at reception. I decided to go for it myself. I asked for the paperwork but no-one seemed to know what I was talking about.

“I told them I was not leaving without it. The receptionist believed it was with the morning locum. I followed her to the room. She knocked but no-one answered. We waited for seven minutes until I demanded she knock again. When she got in the locum said it had been passed to the afternoon locum but there was no answer from his room.

“I begged her to knock again and explained, with patients in earshot, that my mother was drowning and needed help as she was dying.

“I decided just to barge into the room. The doctor was very rude. I explained we needed the directive for the district nurse and he said he had already given it to a family member. I told him he hadn’t and that is why I was there. He insisted he had done it. At that point I was very upset as he was refusing to re-write it.

“I told him the surgery had killed my mother because of the notices up in the surgery saying only one problem was allowed per visit.

“The locum eventually re-wrote the directive. I asked him if he would hurry as my mother was desperate as she has lung cancer and was drowning and he had the audacity to ask, ‘So how long has your mother smoked’ in a critical tone as though it was her own fault. I was so angry. The receptionist was as upset as I was; she couldn’t believe what had come out of his mouth. I said, ‘can you believe he’s blaming my mum who is probably going to die today’. I took the paperwork and left in tears. I got home and gave the district nurse the paperwork. She looked at it and said the doctor hadn’t signed it. I couldn’t believe it.

“She had to go to the surgery herself. She came back and said he was very rude and that she and the receptionist had put in a complaint about him. My mother got her medication late afternoon, after a full day of begging to die.”

A delay in the pump driver working made the woman’s mother very agitated and an ambulance had to be called.

“I begged the staff to give her a top-up of medication. I told my mother I was doing everything I could but she was so scared and in so much pain she genuinely thought I was not helping her on purpose. I of course realise this was also due to the drugs she was on.”

The ambulance driver eventually got through to an on-call doctor who could hear the commotion in the background. The doctor gave the go-ahead for the staff to give the woman’s mother the medication to give her relief.

“They were brilliant, as was the district nurse but shortly after the ambulance left, when mam had calmed down she died an hour later lying in bed with me lying next to her hugging her. It was the worst thing I have ever experienced and I have nightmares every night.”

The woman is now suffering depression and is desperate for help for suicidal thoughts. She has been given an appointment with a mental health unit in February.

Her daughter, too, is struggling with her own experience and seeing how badly her mother has been affected. She has had difficulty getting counselling for her trauma.

The family’s complaint in December to Horsefair has so far gone unanswered.

To read the Oxfordshire Clinical Commissioning Group’s statement regarding Horsefair go to; https://www.banburyguardian.co.uk/health/countless-complaints-about-banburys-horsefair-surgery-posted-social-media-1381714