A medical practice in the Surrey area

3. Mr S complains the Practice:

· did not refer his mother to the hospital soon enough to treat the condition which led to her death · failed to facilitate a face-to-face appointment · failed to carry out blood tests until 4 June 2020.

4. Mrs N died on 12 July 2020. Mr S says the Practice’s failure to facilitate a face-to-face appointment meant it could not see how ill she was. He says the Practice’s delay in carrying out blood tests, and its failure to refer his mother to hospital, prevented her from getting the treatment she needed, and led to her death. Mr S says his mother lost her life as a result of these failings. This has caused additional distress and upset to the family, and they believe had the Practice acted sooner, Mrs N would not have died.

5. Mr S would like the Practice to admit fault and take accountability for its actions.

6. Mr S first contacted the Practice on 1 May 2020 and spoke to a nurse. He explained Mrs N had a fever which improved with paracetamol. The Practice recorded her temperature at 37°C and noted that she was feeling shivery. A urine sample was requested, which was returned to the Practice on 4 May and showed no abnormalities.

7. The Practice was contacted again on 11 May. Mrs N still had a temperature of 37°C at night and a slight cough which Mr S did not think was due to her asthma. COVID-19 was discussed, but Mr S said his mother was not out of breath. He was advised to call back if Mrs N’s symptoms became worse.

8. On 13 May, Mr S contacted 111 because Mrs N had a fever. He was advised to manage this with paracetamol. 111 told Mr S it could be COVID-19 but he disagreed because his mother had been self-isolating.

9. On 15 May, Mr S called the Practice again. He explained his mother had a dry cough and her temperature had reached 37.5°C. The Practice noted she had no shortness of breath, no lethargy, no rash, or pain, and was passing urine. She was also eating and drinking.

10. Mr S called the Practice on 22 May. He told the Practice his mother still had a cough. The Practice prescribed Amoxicillin 500mg capsules for her to take three times a day.

11. On 31 May, Mr S called 111 because he wanted his mother to be put on a drip to gain some strength. She was assessed face-to-face at a different GP Practice where she was described as looking well and comfortable. Her temperature was 37.1°C, heart rate of 90 BPM, respiratory rate of 18PM, and Oxygen Saturation at 97-98%. Mrs N was diagnosed as recovering post COVID-19 and the notes say to speak to the GP regarding a review for further investigation. If there were any changes or deterioration in the interim, Mr S was advised to call back or take Mrs N to the emergency department.

12. On 3 June, Mr S called the Practice and said his mother was no better. She had body aches, was feeling weak, and could only eat small amounts. She did not have a cough or shortness of breath, and she did not have a fever. On 4 June, the Practice took her bloods. Mr S says during this appointment, his mother needed help to get out of her chair.

13. The results from the blood tests came back on 5 June but the GP was only able to review them on 8 June. On Saturday 6 June, the family called for an ambulance. Mrs N was taken to A&E at Hospital A.

14. Hospital A’s first impression was she was suffering with COVID-19, but no test was performed. Mrs N was discharged from A&E with a diagnosis of a fever and lower respiratory tract infection. She was then admitted onto a ward at Hospital A for further monitoring.

15. On 16 June, following a computerised tomography (CT) scan and an ultrasound scan, cholangiocarcinoma of the liver was suspected. This is a type of cancer which forms in the slender tubes (bile ducts) that carry the digestive fluid, bile.

16. A CT scan of Mrs N’s head was performed because she reported right sided weakness in her arms, and a magnetic resonance imaging (MRI) scan confirmed a left parietal occipital infarct: a type of stroke that occurs in the back part of the brain known as the parietal lobe.

17. On 29 June, Mrs N was discharged from Hospital A because the family were keen for her to be at home. The diagnosis upon her discharge was noted as:

· Cholangiocarcinoma – suspected – 26 June · Fever – confirmed – 6 June · Lower respiratory tract infection (an infection in the lungs or below the voice box) – suspected – 6 June · Pulmonary embolism (a blood clot that develops in a blood vessel in the body) – confirmed – 26 June · Stroke (a life threatening condition that happens when the blood supply to part of the brain is cut off) – confirmed – 26 June

18. Biopsy results on 7 July 2020 confirmed an Adenocarcinoma. This is a malignant tumour formed from glandular structures in epithelial tissue and is consistent with cholangiocarcinoma. But because of Mrs N’s medical condition, the decision was made not to operate. Recommendations were made for her to be put under the palliative care team, and she sadly died on 12 July.

22. 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 comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong in the three complaints Mr S has brought to us. We set out our reasons below.

Failed to facilitate a face-to-face appointment

23. Mr S says the Practice failed to facilitate a face-to-face appointment for Mrs N, even though he was continuously expressing she was not getting any better, and he kept calling the Practice. He says as a result, the Practice was unable to appreciate and see how ill she was, which may have impacted how she was assessed and treated.

24. The GMC document, Good Medical Practice, domain 1: ‘Knowledge, skills and Performance,’ along with sub-section ‘Apply knowledge and skill to practice,’ outline the standard expected in the assessment of patients.

25. Paragraph 15 states you must provide a good standard of practice and care and if you assess, diagnose, or treat patients, you must:

a. adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b. promptly provide or arrange suitable advice, investigations or treatment where necessary c. refer a patient to another practitioner when this serve’s the patient’s needs.

26. At the time Mr S first called the Practice about his mother, in May, primary care was operating under additional guidance due to the impact of COVID-19. This included guidance from NHS England, NHS Improvement, and the UK Health Security Agency (formerly Public Health England).

27. As outlined in the April 2020 document from NHS England and Improvement ‘Advice on how to establish a remote ‘total triage’ model in general practice using online consultations,’ a key change was general practitioners had been asked to operate a ‘total triage’ model.

28. Page 2 of the guidance notes how practices were expected to triage all patients by telephone or online, to minimise face-to-face contact, reduce infection risks to staff, and patients, and reduce avoidable footfall in practices. Remote consultations were to be provided along with face-to-face care for those who needed it.

29. Section 4.6 of the Guidance from the UK Health Security Agency, available in April 2020, in a document titled: ‘Covid-19: guidance for maintaining services within health and care settings – infection prevention and control recommendations,’ further supports this by advising, where possible and appropriate, virtual consultations should be utilised in primary care settings. Within this same section, the guidance states patients should not attend primary care settings if they have symptoms of COVID-19.

30. Guidance from NICE Clinical Knowledge Summaries ‘Scenario: Suspected Covid-19 Infection’ (since updated), also says within the section titled ‘Management of suspected coronavirus infection,’ that patients with possible COVID-19 symptoms should not attend their GP practice but contact 111 online instead. In the section titled ‘Diagnosis,’ the guidelines define two of the most common symptoms of COVID-19 as fever and cough. This is further supported in the management section, where it is advised patients with mild symptoms such as fever and/or a cough should stay at home.

31. A BMJ article (BMJ 2020;369:m1845) states most patients with Covid-19 could be managed remotely with advice on symptomatic management and self-isolation.

32. On 1 May 2020, Mrs N already had a one week history of feeling feverish, but with a normal temperature of 37.1°C. There were no concerning features noted in the records. A urine sample was requested which showed no abnormalities.

33. One week later, Mrs N reported intermittent fever with a normal temperature of 37.5°C, and a slight cough. There was no breathlessness or other concerning features. Mr S was advised to call back if her symptoms became worse.

34. On 15 and 22 May, Mrs N had a continuing cough. No other concerning features such as breathlessness, a high temperature, pain or pressure in the chest, blue lips or face, suggestive of shock were noted. The Practice prescribed her with some antibiotics at the 22 May appointment to see if this would help and made a note to review as necessary.

35. With the high frequency of COVID-19, and the additional guidance in place at the time, Mrs N was managed appropriately and in line with the guidelines. The Practice did not see a clinical need to see Mrs N face-to-face following their assessment of her condition, and this was in keeping with the guidance during this period to see patients remotely whenever possible.

36. From our review of the relevant consultations during this period, we can see the Practice acted in accordance with GMC and COVID-19 guidance, and adequately assessed Mrs N each time.

37. We appreciate Mr S told us he was very concerned about his mother’s condition at this point. The remote management of Mrs N’s symptoms as probable COVID-19 was in keeping with the situation and her reported symptoms of cough and fever. She did not warrant a face-to-face appointment as she did not report any red flag symptoms as referenced in the above paragraph. She was presenting with two of the most common symptoms of COVID-19, a cough and fever, and no other symptoms were reported at the time to prompt the Practice to think there were other issues requiring further investigation, or the need to have a face-to-face consultation.

38. Based on these guidelines, and the clinical advice from our independent GP adviser, it is our understanding the care and treatment provided by the Practice was in keeping with the guidance. There are no indications of failings based on the information we have seen, however, we do not underestimate how upsetting and distressing this experience has been for Mr S and his family.

Did not refer his mother to the hospital soon enough

39. Mr S complains the Practice did not refer his mother to Hospital A soon enough to treat the condition which then led to her death.

40. The guidelines mentioned above are also applicable here, in particular, the BMJ Article which states most patients with COVID-19 could be managed remotely with advice on symptom management and self-isolation. As mentioned above, Mrs N reported a one week history of feeling feverish on 1 May with a normal temperature of 37°C.

41. A week later, she reported intermittent fever (with a normal temperature) and a slight cough. She was not breathless.

42. On the 15 and 22 May, she had a continuous cough but no other concerning features. She was prescribed antibiotics by the Practice and did not present with symptoms, to suggest the need for hospital admission, for example difficulty breathing, pain or pressure in the chest and blue lips or face suggestive of shock. There was no way of determining whether she had COVID-19 at that stage because COVID-19 testing was not available. We can see the Practice gave some safety netting advice and advised the family to look out for Mrs N’s temperature going above 38°C and not reducing, her becoming short of breath, developing a rash or becoming lethargic.

43. Mrs N was seen in person after contacting 111 on 31 May and her observations were taken. She had a slightly raised respiratory rate, but all other observations were normal. In view of this, she did not meet the threshold for a hospital admission as per page 3 of the BMJ Article i.e., a temperature above 38°C, breathlessness and low urine output. Given the results of these observations, our adviser said it is also unlikely she would have been admitted to hospital any sooner had the Practice carried out an assessment prior to this.

44. The Practice was contacted again on 3 June because Mrs N was experiencing aching and weakness. Her cough had resolved. She had no shortness of breath, no fever, and was passing urine. She was drinking but only eating small amounts. Blood tests were arranged for the following day. The results indicated mild anaemia and significantly elevated C-reactive protein (CRP). This is a protein made by your liver which is sent into your bloodstream in response to inflammation, with inflammation being your body's way of protecting your tissues if you have been injured or have an infection.

45. CRP is an inflammatory marker that would require further investigations if it was raised. As the results were received by the doctor on the 5 June, and Mrs N was admitted to hospital via A&E on 6 June, if a re-assessment had been carried out sooner regarding these abnormal blood results, and an admission to hospital was deemed necessary following this, Mrs N would only have been admitted to hospital a day sooner at the earliest.

46. It is our understanding therefore that the care and treatment provided by the Practice was in keeping with the relevant guidance and there are no indications of failings. We appreciate the challenging time Mr S and his family have been through, and we hope this has provided some reassurance.

Failed to carry out blood tests until 4 June 2020

47. Mr S says the Practice should have carried out blood tests earlier than the 4 June. He says he continuously called the Practice telling them she was not getting better, and the Practice should have acted sooner. Mr S says if bloods were taken earlier, the result would have highlighted the anaemia and significantly raised CRP, meaning Mrs N would have been treated sooner and would not have died.

48. Mrs N presented with two of the most common symptoms of COVID-19, a cough and fever, throughout May. On 3 June, when the Practice were informed her cough had resolved but she was suffering with aching and weakness, blood tests were arranged for the following day. As noted above, the results indicated mild anaemia and significantly elevated CRP. These results were received on 5 June, and Mrs N was admitted to hospital via A&E on 6 June. As stated above, reassessment at an earlier date regarding these blood results, would only have resulted in Mrs N being admitted a day sooner, if indeed an admission was deemed necessary.

49. There is nothing in the COVID-19 guidelines we have referenced above which directs a Practice to take bloods when COVID-19 is suspected. The Practice suspected Mrs N had COVID-19 throughout May. On her admission to hospital on 6 June, she was diagnosed with possible lower respiratory tract infection, confirmed pulmonary emboli (a blockage in one of the pulmonary arteries in your lungs) or clots in both lungs, and a stroke.

50. She was treated with antibiotics to cover infection of the biliary ducts (the small tubes that carry bile outside the liver), and a CT scan showed possible cholangiocarcinoma (cancer of the biliary duct), with possible wider spread to other locations. There was also a probable clot in the portal veins in the liver.

51. A biopsy confirmed cancer and in view of the many medical problems Mrs N was suffering from, it was felt that she was not well enough for surgery for the cholangiocarcinoma. Review by the cancer specialist was planned, and to consider chemotherapy if appropriate. Mrs N subsequently died on 12 July. The cause of death was noted as cholangiocarcinoma. Because of the cancer diagnosis, our adviser says earlier admission in May was unlikely to have prevented or significantly delayed her deterioration and death.

52. If Mrs N’s symptoms in May were due to infection, she would not have been well enough for surgery or chemotherapy at an earlier date. If she already had pulmonary emboli rather than infection, which the normal oxygen saturations and pulse on 31 May makes less likely, earlier admission may have led to earlier treatment of the clots, but she would again unfortunately have been unable to have any treatment for the cancer.

53. Mrs N sadly deteriorated very rapidly due to the cancer picked up on the CT scan, which suggested it had already spread. Earlier referral (in May) was unlikely to have affected the outcome, even if some treatment was possible.

54. When considering the guidelines above and the clinical advice obtained from our adviser, it is our understanding the Practice acted in line with the relevant standards in place at the time. We appreciate Mr S and his family may be disappointed with this outcome, but we hope we have been able to give him answers to the concerns he has raised.

1. We have carefully considered Mr S’s complaint about a medical practice in the Surrey area (the Practice). We recognise he and his family have been through a very difficult time with the care and treatment provided to Mr S’s mother, Mrs N, by the Practice. Mrs N sadly died on 12 July 2020.

2. After much consideration, and obtaining clinical advice from an independent GP expert, we have seen no indication that anything went seriously wrong with the care and treatment provided to Mrs N by the Practice, between May and July 2020.