The Practice
Urological symptoms
23. Mrs V says that between April 2015 and October 2017 the Practice did not act on Mr V’s urinary symptoms and test results.
24. GMC’s Good Medical Practice says doctors should:
· adequately assess the patient’s conditions and take into account their history (including symptoms) their views and values · promptly provide or arrange suitable advice, investigations, or treatment where necessary · refer a patient to another practitioner when this serves the patient’s needs.
25. The NICE guidance for UTIs in men also provides advice around diagnosing and managing a UTI. This says that when diagnosing a suspected UTI, doctors should confirm the diagnosis by sending a sample of the patient’s urine for testing.
26. Mr V had a history of blood in his urine. This was sometimes visible and sometimes only present on urine dipstick tests. Blood in the urine is a common symptom of a UTI. Mr V also had other symptoms which were suggestive of a UTI, including dysuria and nocturia.
27. The Practice sent Mr V’s urine to the laboratory to test for infection on 29 September 2016, 10 March 2017, 9 June 2017, and 11 October 2017. This was in line with the GMC and NICE guidance. The results did not show that Mr V had a UTI at any stage.
28. Our GP adviser explained that the absence of infection would usually prompt a GP to begin considering other causes of the blood in the urine. This may include a referral to the urologists in line with the GMC guidance.
29. However, we can see from Mr V’s historic GP records that in 1996 his previous GP Practice referred him to urology regarding blood in his urine. The urology team investigated Mr V’s symptoms but found no underlying cause.
30. In 2009, his previous GP Practice referred him to urology again. The urology team performed a cystoscopy, the results of which were normal. Again, the urologist found no underlying cause for his urinary symptoms.
31. It is not clear from the medical records if the GPs at the Practice looked back on Mr V’s past medical history. In general, the consultation notes contain a level of detail below which we would expect to see.
32. Our GP adviser explained that because urology had already investigated Mr V twice, they would not have expected the Practice to refer him to urology again, regarding blood in his urine. Taking this advice into account, we are not critical of the Practice for not making this referral.
33. We can see Mr V went for an ultrasound of his bladder and kidneys in 2016. The ultrasound found his kidneys were normal. The radiologist recorded in the ultrasound report that Mr V had a trabeculated bladder.
34. We can see that following the ultrasound scan, a GP at the Practice discussed the results with Mr V. On questioning Mr V about his symptoms and looking at his history, they concluded this finding was nothing to be concerned about.
35. Our GP adviser was not concerned the Practice did not taken any action in relation to this finding. We are further reassured that Mr V’s post-mortem found his bladder was normal, which supports the Practice’s decision not to have acted.
36. Although we would not have expected the Practice to refer Mr V to urology again, our GP adviser said the Practice should have suspected a condition called glomerulonephritis. This is a condition which can also cause visible or non-visible blood in the urine.
37. In line with the GMC guidance, the Practice should have considered referring Mr V to a nephrologist who could have ruled out this diagnosis. The Practice did not do this which we consider to be a failing.
38. Glomerulonephritis is a rare condition and we do not know if Mr V had it. His post-mortem could not comment due to kidney changes caused by the pyelonephritis.
39. Our GP adviser explained that even if Mr V did have this condition, it would not have contributed to him developing pyelonephritis and his subsequent death from sepsis in 2017. He explained that pyelonephritis is a condition which develops quickly over hours or days.
40. Taking this advice in to account, we have not found this failing contributed to Mr V’s subsequent death. We have made a recommendation to the Practice though to help prevent a similar mistake happening again.
41. We also note the Practice did not see Mr V in the weeks prior to his death, following his discharge from hospital in September.
42. We are not critical of the Practice for not arranging a follow up with Mr V following his discharge from hospital. The Practice repeated his blood tests and reviewed his medication as the hospital advised in its discharge letter. This was in line with the GMC’s Good Medical Practice.
43. We can also see the Practice sent a urine sample for analysis on 11 October which did not show evidence of infection.
44. The Practice sadly had no way of detecting the pyelonephritis or taking any action which could have altered the outcome for Mr V.
Abdominal symptoms
45. Mrs V also says the Practice did not act on Mr V’s abdominal symptoms.
46. Our GP adviser explained there is no NICE guidance specific to abdominal pain and so the relevant guidance is still GMC’s Good Medical Practice, which says to adequately assess the patient’s condition, examine them, and arrange appropriate investigations and treatment.
47. We can see three occasions where Mr V complained of abdominal symptoms. The first of these was April 2015 where a GP examined him and took his history. They noted his examination and urine dipstick were normal. Because of this, he would not expect the Practice to have arranged any further investigations at that stage.
48. Following this, Mr V did not complain of any abdominal symptoms again until November 2016. At this time, a GP examined his abdomen and noted it was normal. The GP also retested for blood in Mr V’s urine the following week. It appears the GP suspected he may have constipation. Mr V was also awaiting the results of an ultrasound scan too.
49. Mr V returned in June 2017 with diarrhoea, vomiting, and ‘tummy cramps’. The GP examined him and diagnosed a suspected diarrhoea and vomiting bug. Our GP adviser explained this was consistent with the symptoms which Mr V had.
50. We understand why Mrs V had concerns about her brother’s symptoms. However, our overall decision is the Practice acted in accordance with GMC guidance on each of these occasions. We can see no reason the Practice would arrange any onward referrals or investigations at any stage for Mr V’s symptoms. Our GP adviser also said Mr V’s abdominal symptoms were not connected to him developing pyelonephritis in October 2017.
AKI warning September 2017
51. Following Mr V’s discharge from hospital in September 2017, the hospital recommended the Practice carry out blood tests a week later to check Mr V’s sodium levels. The Practice carried out this test in line with GMC guidance. We note the Practice also sent a urine sample at the same time. It is not clear why the GP sent this as the hospital had not recommended it.
52. When the results of the tests returned, they showed Mr V had no evidence of infection but that his eGFR was low, indicating he may have an AKI.
53. We considered if the Practice should have taken any action in response to the AKI warning. Our GP adviser explained Mr V’s tests results showed he only had a very mild reduction in his kidney function as his eGFR was 58 (normal would be an eGFR greater than 60).
54. NICE guidance for chronic kidney disease states clinicians should take the following steps to identify the rate of progression of kidney disease:
· obtain a minimum of three eGFR estimations over a period of not less than 90 days · in people with a new finding of reduced eGFR, repeat within two weeks to exclude causes of acute deterioration of eGFR.
55. As this was a new finding of reduced eGFR, we would have expected the Practice to repeat the test within two weeks for Mr V (by no later than 25 October). We cannot see whether the Practice made any attempts to arrange this. However, we also note Mr V sadly died prior to the two weeks elapsing.
56. It is possible the Practice may have arranged the eGFR test by the end of the two-week period. However, because Mr V sadly died prior to this, we now do not know whether the Practice would have done this. Either way, it seems unlikely it would have been able to arrange relevant investigations or treatment in such a short period of time.
57. Taking this into account, we have found no failings in this element of Mr V’s care.
The Trust
58. Mrs V says that during Mr V’s emergency admissions in May and September 2017, the Trust failed to provide appropriate treatment or follow up for his seizures, caused by low sodium levels. Mrs V says the Trust did not stop Mr V’s prescription of carbamazepine.
May admission
59. The NICE guidance for hyponatraemia provides advice to clinicians around the management of low sodium. This says that for chronic hyponatraemia without moderate or severe symptoms, clinicians should stop non-essential medications that can cause it.
60. When Mr V presented to hospital in May, doctors noted he had a sodium level of 124. The NICE guidance considers this to be ‘moderate’ hyponatremia. The admitting team noted that Mr V’s low sodium was chronic. His sodium levels had previously been 130 which the NICE guidance considers ‘mild’ hyponatraemia.
61. At the time of this admission, Mr V was taking carbamazepine, which isa medication that can cause hyponatraemia. The clinical records indicate he was taking this for his mental health as a mood stabiliser.
62. The treating team decided to continue this medication as they believed it was essential for the treatment of these conditions. Mrs V advises us that a psychiatrist had previously said her brother no longer needed this medication. However, there is no evidence the treating team were aware of this at the time they decided to continue the medication.
63. Our physician adviser explained information provided by Mr V’s carer supported the decision to continue. The treating team documented they would consider changing it if Mr V’s sodium remained low.
64. We also note the clinical team concluded Mr V’s vomiting and dehydration was causing his low sodium, and so the worsening of his hyponatraemia was recent. Our physician adviser explained Mr V’s sodium levels improved quickly with intravenous sodium chloride. This treatment was in line with the NICE guidance.
65. On discharge, the hospital staff recommended that Mr V’s GP Practice repeat his blood tests in a week. This was in accordance with NHS England’s guidance which states clinicians should put appropriate systems and safety net arrangements in place to ensure any follow up tests required after discharge are performed. The GP records indicate this retesting occurred.
66. In summary, we can see the treating team identified the cause of Mr V’s hyponatraemia on admission and provided the correct treatment for this. They were concerned stopping his carbamazepine may have negative effects on his mental health and so they decided to only stop it if his sodium levels did not improve. Mr V’s sodium levels did improve. They also ensured appropriate safety netting was in place through Mr V’s GP.
67. We have found the care provided was in line with NICE and NHS England guidance.
September admission
68. The focus of Mr V’s second admission to hospital in September was to treat ‘severe’ hyponatraemia with a clear suspected cause (his carbamazepine medication).
69. Following admission, we note the clinical team documented they considered carrying out urine osmolality (a measure of urine concentration) and urinary sodium tests. Our physician adviser explained these tests would have been useful in identifying how likely it was that carbamazepine was the cause of the low sodium.
70. The Trust has provided us with evidence that it completed the urine osmolality and sodium tests. This was in line with the NICE guidance for diagnosing hyponatraemia.
71. During this admission, we can see the clinical team correctly identified the cause of the seizures as being low sodium caused by the carbamazepine medication. They stopped Mr V’s carbamazepine medication in line with the NICE guidance.
72. We can again see the Trust safety netted in line with the NHS England guidance by advising the GP of the plan to reduce then stop the carbamazepine medication. They also advised the GP to retest Mr V’s blood a week following discharge. We can see the GP Practice did this and his sodium levels had improved.
73. We are not critical of the management of Mr V’s low sodium during this admission.