14. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by considering relevant law, policy, guidance, and standards to inform our thinking. We may also use, where relevant, our clinical adviser’s professional judgement. This allows us to compare what should have happened and what did happen.
Staff did not correctly review and treat Mrs L’s dementia
15. National Institute for Health and Care Excellence (NICE): Dementia: Goals and Outcomes: QEF Indicators outline the 35-70% percentage thresholds for patients diagnosed with dementia, whose care plan has been reviewed in a face-to-face review in the preceding 12 months. Our adviser says GPs are encouraged to monitor patients under the Quality Outcome Framework where it is recorded as DEM004.
16. Ms A says the Practice did not correctly review and treat her mother’s dementia. In her complaint, she says she witnessed a decline in her mother’s health over a period from discharge where she could not open her eyes, speak, eat, or drink, and her condition shocked the family.
17. The Practice says since Mrs L’s discharge from hospital in November 2017, she was reviewed by many clinicians face to face, by telephone consultations, and home visits. It says at each review, Mrs L’s holistic needs were considered. These included the current clinical issue, past issues, and the monitoring of treatment (both acute and follow-ups).
18. Our adviser explained the percentage thresholds we referred to earlier are the minimum review interval, whereas most dementia patients are seen on other occasions such as for a Urinary Tract Infection (UTI), chest infection, or direct issues relating to dementia itself. A dementia review would include both a physical and mental assessment and review of the dementia plan.
19. We have carefully considered Mrs L’s clinical records and her consultations in May 2018, November 2018, October 2019, March 2020 and July 2020. We have seen evidence from her records that her dementia was assessed, and care plans recorded at these consultations. Mrs L was also being seen by a community matron experienced in dealing with the elderly, housebound population. The matron also involved the Occupational Health Team (OT) in her care.
20. As such, in line with guidance, we consider there is evidence in Mrs L’s records that staff reviewed and managed her dementia, and we have seen no indications of a failing with this. We will therefore take no further action.
Staff did not consider Mrs L’s dry cough, occasional chest tightness, and shortness of breath
21. Justification of exposure, including referral criteria and exposure protocol guidelines, explains what indications justify ordering a chest X-ray.
22. The Practice says the chest X-rays that were requested over a period did not indicate the possibility of lung cancer, and more recent X-rays were compared to older ones.
23. Our adviser says chest X-rays are ordered by staff based on a patient’s clinical grounds, for example, if they have a cough, or suspected they may have a chest infection, or heart failure.
24. As explained in the guidelines we referred to, there are several indications to consider when ordering X-rays. The X-rays are done at a hospital and the results are then sent through to the GP. Our adviser says a GP does not ever see the chest X-ray itself but relies on a radiologist’s report and their subsequent advice. This advice can sometimes be added into the report and may say ‘repeat chest X-ray in four to six weeks’. A radiologist will also have the benefit of comparing previous chest X-rays, if available, to see if there are changes over time.
25. Mrs L had a chest X-ray in January 2018 for ankle swelling and a pleuritic cough. This was reported by a radiologist as clear, but with a granuloma seen on the X-ray of no clinical significance. Mrs L’s records in August 2018 indicate she had a consultation in which she explained she had some weight loss, and another chest X-ray was requested. This X-ray was reported as ‘normal X-ray. Incidental granulomata that do not routinely require any further follow up/investigation’.
26. In October 2019, Mrs L’s records indicate she had a consultation for a persistent cough that she had had for two to three years, and a further chest X-ray was then requested to investigate further. This was reported as ‘non-specific ill-defined nodular density between second to third rd. Rib on left side. ?artefact’. The radiologist’s report also advised Mrs L needed to repeat her chest X-ray after two weeks. We can see staff requested this repeat X-ray within two weeks and a radiologist reported it as ‘no further change, the prior subtle changes are therefore of doubtful significance and no further follow-up is recommended’.
27. In July 2020, Mrs L was discharged from hospital after collapsing. Her records indicate she had been diagnosed with dehydration and AKI. On the 28 July, hospital staff called the Practice and explained that on review of her chest X-ray, the radiologist thought that the changes seen were likely to be metastatic lung cancer probably arising from the lung itself.
28. Our adviser explained there was evidence to show staff did consider Mrs L’s dry cough, occasional chest tightness, and shortness of breath, and they had arranged the appropriate tests including multiple chest X-rays to investigate further.
29. The X-rays were reported to the Practice by a radiologist as being not clinically significant, and only when reviewed following her admission to hospital in July 2020, was a diagnosis made of a probable lung cancer (that had spread within her lungs). Our adviser says the results of the chest X-rays were not within the Practice’s control as staff were wholly reliant on the radiologist’s reporting of these.
30. After taking this all into consideration, we have seen no indications of failings with the Practice staff’s consideration and approaches to Mrs L’s dry cough, shortness of breath, and breathing symptoms and will therefore take no further action.
In June 2020, staff did not have a face-to-face consultation with Mrs L and incorrectly prescribed antibiotics based on her symptoms
31. PHE: Diagnosis of urinary tract infections reference tool explains in pages eight to ten about dealing with suspected UTI’s in patients over 65. It also has specific advice about elderly frail patients which states ‘only take urine sample if symptomatic and able to collect good sample. If incontinent, clean catch in disinfected container and condom catheters for men may be viable options but little evidence to support’.
32. This tool also states men and woman over 65 may present with:
· localised signs or symptoms of a UTI including new onset dysuria; incontinence; urgency1B+ · temperature: 38°C or above; 36°C or below; 1.5°C above normal twice in the last 12 hours2B+,3D,4B- · non-specific signs of infection: for example, delirium; loss of diabetic control.
Lastly, this tool states ‘do not perform urine dipstick as they become more unreliable with increasing age over 65 years’.
33. NHS: Access to general practice communications toolkit explains face-to-face appointments are available to patients where there is a clinical need. You will be asked to first discuss your conditions over the phone or online with a member of the healthcare team to assess what would be most appropriate for you, and which practice member would best provide it.
34. An article from the Medical Protection organisation on the risks of phone consultations says: ‘it is important to remember that you must put yourself in a position to justify the diagnosis and management plan you make in the context of a telephone consultation, and if there is any doubt then a face-to-face consultation should be arranged’.
35. Ms A says in June 2020, staff did not carry out a face-to-face consultation and her mother was incorrectly prescribed antibiotics for a UTI, based on her symptoms. She says Mrs L had an AKI which was diagnosed by the hospital after she had been admitted.
36. The Practice says Mrs L’s husband contacted them and explained she had been complaining of increased painful urination, and offensive smelling urine that had been persisting for one week. The duty doctor assessed this information and based on current symptoms, and past episodes of UTI’s, made a further diagnosis of a UTI and prescribed an appropriate antibiotic and follow-up plan.
37. Mr L contacted the Practice in June 2020, it was during the COVID-19 pandemic when staff were working under exceptional circumstances and only offering face to face appointments where they considered there was clinical need, as explained in the toolkit.
38. Our adviser explained that in line with the Medical Protection Association’s article, it was appropriate to treat Mrs L following a telephone appointment, even before COVID-19 times, as she had sufficient signs and symptoms for the GP to put themselves in a position to justify their diagnosis and management.
39. Mrs L’s husband explained that his wife had increased frequency, and dysuria (pain and discomfort passing urine). Her urine smell indicated no fever or loin pain. Mrs L’s records indicate she had previous similar episodes of suspected UTI’s that had responded to antibiotics. Our adviser says the GP reasonably prescribed an appropriate course of antibiotics (for another suspected UTI) by telephone.
40. Our adviser also explained the Practice’s explanation of the treatment of Mrs L’s UTI and relationship to the AKI is robust and supported by the evidence in her records. As such, in line with guidance, we have seen no indications of failings that staff did not treat Mrs L’s symptoms appropriately, or there was a need for her to have a face to face consultation, and that she was correctly prescribed antibiotics. We will therefore take no further action.