An urgent care centre in the Stoke-on-Trent area

6. Mrs I complains about the way her husband, Mr I, was triaged by staff at the urgent care centre. Specifically, she complains that during the 111 call, the doctor told her husband to remain at home and take paracetamol for his symptoms. Mrs I says the doctor should have checked his oxygen levels and he should have been taken to hospital straight away.

7. She says her husband should have received treatment sooner and the delay meant he died. This has caused her significant upset and distress.

8. She would like an acknowledgement and explanation for the failings. She would also like an independent investigation into the events she complains of.

9. Mr I tested positive for COVID-19 on in October.

10. He called 111 at 5.24pm two days later as he was feeling unwell. He told the call handler he had shortness of breath when going to the toilet and it took him time to recover from this. He also said he could not do normal daily activities and his breathing was faster than normal at rest.

11. The 111-call hander triaged his call and confirmed he needed a telephone assessment with a doctor. They ended the call and Mr I waited for a doctor to call him back.

12. At 5.39pm, the doctor called Mr I back. Mr I told the doctor he could only walk between the bed and the toilet. He said he could not go downstairs. Mr I also said he could eat, but only slowly. The doctor advised him to stay at home and take paracetamol. The doctor also advised him to call 999 if his clinical condition deteriorated. The doctor did not arrange for his oxygen levels to be checked.

13. The following day, Mrs I noticed a marble effect had appeared on Mr I’s back. She rang 999 at 10.53pm. The ambulance arrived at 11.12pm. After assessing Mr I, paramedics took him to the hospital. Mr I arrived at the hospital at 12.14am. He had a rapid heart rate, low blood pressure, acidic blood, and very low oxygen saturations.

14. Unfortunately, soon after arriving at the hospital, Mr I suffered a cardiac arrest. Although doctors carried out cardiopulmonary resuscitation (CPR), Mr I sadly died one hour later.

19. Mrs I is concerned about the way the doctor assessed her husband during the 111 call. This is because he sadly died two days later. She explains that if the doctor had checked her husband’s oxygen levels, it may have led to him receiving treatment sooner. She says he would not have sadly died if this had happened.

20. The urgent care centre circulated the Telephone Triage Guide to its doctors in March 2020 and an updated version in June 2020. This was to aid doctors in handling 111 calls in patients suspected of having COVID-19. The doctor said they did not rely on the Telephone Triage Guide when assessing Mr I’s clinical condition.

21. Our Principles of Good Administration say public bodies should follow its own procedural guidance.

22. In line with our Principles of Good Administration, we would have expected the doctor to follow the urgent care centre’s procedural guidance by taking into consideration the Telephone Triage Guide. They did not do this. We identify this as a failing.

23. The Telephone Triage Guide says doctors should evaluate a patient’s breathlessness by asking: - “Open Questions - How is your breathing today?

- 111 symptom checker - Are you so breathless that you are unable to speak more than a few words? Are you breathing harder or faster than usual when doing nothing at all? Are you so ill that you’ve stopped doing all of your usual daily activities?

- Focus on Change - Is your breathing faster, slower or the same as normal? What could you do yesterday that you can’t do today? What makes you breathless now that didn’t make you breathless yesterday?

- Interpret the breathlessness in the context of the wider history and physical signs”

24. It says patients who have moderate symptoms (mild shortness of breath, can complete full sentences, lethargic but able to self-care) should manage their symptoms at home. They should also be advised to take paracetamol.

25. It also says patients who have severe symptoms (significant shortness of breath at rest, cannot complete full sentences, overwhelming fatigue and unable to self-care) should undergo an emergency assessment through 999. A patient’s oxygen saturations would have been checked during this assessment.

26. During the 111 call, Mr I told the doctor he could only walk between the bed and the toilet. He said he could not go downstairs. Mr I did say he could eat, but slowly.

27. Our GP adviser told us if the doctor had used the Telephone Triage Tool, as they should have done, the doctor would have also asked ask Mr I if: - He was breathing harder or faster than normal at rest - He was breathing faster, slower or the same as normal at rest - He could perform all of his usual daily activities

28. Our GP adviser explained if the doctor had used the Telephone Triage Tool’s questions, based on the answers Mr I provided to these during the 111 earlier on, Mr I’s clinical condition would have fallen between the moderate to severe category.

29. This means that advising Mr I to manage his conditions at home, while taking paracetamol, was in line with the Telephone Triage Tool. However, Mr I was unable to perform daily activities, it took him time to recover his breath after going to the toilet and his breathing was faster than normal at rest. This shows his oxygen levels needed additional monitoring.

30. Our GP adviser explains the doctor should have arranged for Mr I’s oxygen levels to be assessed for these reasons.

31. The doctor said they took into consideration NHS England’s guidance on pulse oximetry when assessing Mr I’s clinical condition. We have also carefully considered NHS England’s guidance on pulse oximetry to see what the doctor should have done in line with this.

32. NHS England’s guidance on pulse oximetry says if a patient meets the criteria for management at home, doctors should plan an assessment using an oximeter. This is a device which measures oxygen levels in the blood. This can either be in an out of hours setting, or the doctor can organise for a pulse oximeter to be delivered to the patient at home.

33. At the time, the doctor told Mr I he should manage his symptoms at home with paracetamol. Therefore, they deemed him suitable for management at home.

34. In accordance with NHS England’s guidance, the doctor should have then organised for Mr I’s oxygen levels to be checked. The doctor did not do this. We identify this as a failing.

35. We think the doctor should have arranged for Mr I’s oxygen levels to be assessed after the call they had with Mr I. We have considered what impact the failings we have identified are likely to have had in our ‘impact of failings’ section below.

Impact of failings

36. Our critical care adviser explained various factors can contribute to changes in oxygen levels in a patient. This includes the rate at which the COVID-19 progresses, blood clots, how much fluid a patient is taking in, their blood pressure and levels of inflammation. Our critical care adviser explained all of these may also interact in varying ways.

37. Our critical care adviser explained it is likely Mr I had low oxygen levels when exerting at the time of the call with the doctor. This is because he was breathless when going to the toilet, it took some time for his breath to recover from this, and he was breathing faster than normal.

38. Due to the fluctuating factors we have identified in paragraph 36, it is not possible to determine, or make a balance of probability decision on, what Mr I’s oxygen levels may have been soon after the call he had with the doctor.

39. Therefore, we cannot determine what treatment Mr I should have received. We also cannot comment on whether this treatment would have improved his clinical condition. Unfortunately, this means we cannot say whether the failings we have identified contributed to or caused Mr I’s sad death.

40. We recognise not knowing what could have happened, had the failings we have identified not occurred, is a significant injustice. This is likely to be very upsetting and distressing for Mrs I. We also recognise this impact is everlasting. We understand that Mrs I feels Mr I could have survived, and we regret that we cannot provide her with a definite answer on this.

41. We have made recommendations we hope will go some way to recognising the impact the failings we have identified have had. We have also made recommendations which will prevent this happening again. These are set out in our ‘recommendations’ section.

1. Mrs I is understandably concerned the doctor did not appropriately assess her husband, Mr I, when he spoke to them during a 111 call in October 2020. This is because he sadly died two days later.

2. We have found the doctor did not follow the relevant guide to triaging telephone calls during the COVID-19 pandemic. We have also found the doctor did not organise an assessment of Mr I’s oxygen levels after the 111 call.

3. As no assessment took place, we cannot say, even on the balance of probabilities, what Mr I’s oxygen levels were. Because of this, we cannot say what treatment plan he would have likely received at the time. Unfortunately, this means we cannot say whether treatment would have changed the sad outcome.

4. We recognise this uncertainty is likely to cause Mrs I significant, everlasting upset and distress. This is because she is left not knowing what could have happened had the failings identified not occurred. For this, we recommend that the urgent care centre apologise to Mrs I and put in place an action plan to ensure the failings we have found do not reoccur.

5. It is therefore likely we will partly uphold the complaint.

42. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

43. With that in mind, we recommend that within one month of the final report, the urgent care centre should provide an apology to Mrs I. An apology means it should acknowledge the failings identified, accept responsibility for them and express sincere regret for any resulting injustice.

44. The urgent care centre should recognise the everlasting significant upset and distress the failings we have identified in this report have caused. It should recognise Mrs I has been left not knowing what could have happened had the failings not occurred. These failings are: - The doctor did not consider the Telephone Triage Guide during the call with Mr I, as they should have done. Because of this, the doctor did not organise for Mr I’s oxygen levels to be checked soon after the call.

- The doctor did not follow the guidance provided by NHS England on pulse oximetry, as they should have done. Because of this, the doctor did not organise for Mr I’s oxygen levels to be checked soon after the call.

45. Our principles also say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service.

46. With that in mind, we recommend that within three months of the final report, the urgent care centre must provide an action plan which details why the failings identified in paragraph 44 occurred and what actions it will take to prevent these failings from being repeated.