3. Mrs A complains that a GP Practice in the Cambridgeshire area (the Practice) did not arrange for a doctor to see her daughter in April 2021. She complains that the Practice did not arrange any immediate treatment.
4. Mrs A says the family has been left wondering whether S’s death could have been prevented. She is devastated and broken hearted. The outcomes she seeks are service improvements.
5. S was a young woman who was supported by her family when attending medical appointments. Her grandmother called the Practice to request an appointment for her in April. The Practice arranged for S to be seen by a nurse practitioner (a nurse with extra training who can treat and diagnose patients who have minor illnesses).
6. The Practice contacted S and her family later that day to tell them S should go to hospital. S was seen at the hospital at 4pm that day.
7. She was kept in hospital, as the investigations raised concerns about possible symptoms of heart failure. The hospital started medication for this and ordered an in-patient cardiac MRI (a non-invasive test that uses magnetic and radio waves to show detailed pictures of the inside of the heart) at another hospital. Mrs A stayed with S during the admission, and it appeared that her condition was improving.
8. Three days later, S had a sudden collapse in hospital with a cardiac arrest. Sadly, she died that day from heart failure.
The Practice’s decision that S should see a nurse
12. When S’s grandmother rang to arrange an appointment, the call was triaged by the GP who decided S should see the nurse practitioner. Some GP Practices use a triage system to make decisions about allocating appointments.
13. The decision to triage the appointment and decide who should see S was in line with the GMC guidance ‘Leadership and management for all doctors’ which says: ‘When making decisions about using resources, you must … provide the best service possible within the resources available, taking account of your responsibilities towards your patients and the wider population’ and, ‘Make sure that decisions about setting priorities that affect patients are fair and based on clinical need and the likely effectiveness of treatments’.
14. Mrs A’s representative told us the symptoms S was experiencing were clear signs that she should have been seen by a doctor and that it was neglect that this did not happen. We understand why the family think this, as it seems they did not know S would be seeing a nurse rather than a doctor. We think it would have been better if this had been made clear to the family in the call.
15. We asked our GP adviser about who should have seen S. They explained the information shared in the telephone call did not raise any concerns that would mean it was essential for S to see a GP. The GP’s decision to delegate the consultation to the nurse practitioner was in line with the GMC guidance ‘Good Medical Practice’, which says:
‘When you do not provide your patients’ care yourself, for example when you are off duty, or you delegate the care of a patient to a colleague, you must be satisfied that the person providing care has the appropriate qualifications, skills and experience to provide safe care for the patient’.
16. We can see the GP advised the nurse what action to take and the nurse was working under their supervision. The appointment was carried out in line with what the GP had asked the nurse to do, and this directed consultation was in line with the ‘Good Medical Practice’ guidance which says: ‘you must 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’ and, ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.
17. For these reasons we do not uphold this part of the complaint.
The appointment with the nurse
18. The NMC guidance ‘The Code’ explains how a nurse should work in partnership with other colleagues. It says: • ‘respect the skills, expertise and contributions of your colleagues, referring matters to them when appropriate • maintain effective communication with colleagues • keep colleagues informed when you are sharing the care of individuals with other health and care professionals and staff • accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care’.
19. We consider the consultation was carried out in line with this guidance. The nurse undertook the consultation as directed by the GP. She examined S in line with the GP’s request. She dipped and sent the urine sample, attempted blood sampling, examined the ankle swelling, examined her chest, took physiological observations which were normal, and gave advice on what to do should S’s condition worsen. She discussed her findings with the GP.
20. These steps were in line with the expectations of ‘The Code’ and so we do not find any failings and do not uphold this part of the complaint.
The Practice did not arrange immediate treatment
21. As outlined in paragraphs 19 and 20, the nurse acted in line with ‘The Code’ and there was nothing in the examination to make them think they needed to take immediate action.
22. The nurse practitioner discussed the consultation with the GP. The records show the nurse practitioner wrote an account of the discussion and the findings shortly after the appointment. The GP reflected on S’s symptoms and consulted with a colleague at the hospital. This was around two and a half hours after the appointment. This was in line with ‘Good Medical Practice’ which says:
‘If you assess, diagnose or treat patients, you must: promptly provide or arrange suitable advice, investigations or treatment where necessary’ and ‘refer a patient to another practitioner when this serves the patient’s needs.’
23. After the doctor decided S should be seen at hospital, there was no delay in them contacting the family. The notes were written at 2.06pm and show the GP called and texted the family. This was completed in a reasonable timeframe, given the context of the GP carrying out other duties at the same time.
24. We understand the reasons why Mrs A has been left wondering if S’s death could have been prevented. We can see this has had a deep impact on the whole family. We asked our GP adviser for their view on this. They explained there was nothing in S’s symptoms and examination findings to suggest that she needed immediate hospital treatment. Her condition was clinically stable measured over hours and so the actions the GP took were timely.
25. Our GP adviser said immediate hospital referral would not have led to a different care plan. There was nothing additional that could have been done by the Practice that would have made a difference to the sad outcome three days later.
26. For these reasons we found no failings and do not uphold this part of the complaint.
Conclusion
27. We have not upheld the complaint as we have not seen any evidence of failings in what happened.
28. We know Mrs A has been deeply distressed and we are grateful for the time she and her representative took to speak to us about their experience. We hope she will be reassured that we recognise the family did all that they could for S.
1. We have not identified any failings in the Practice’s decision that Mrs A’s daughter, S, should see a nurse rather than a doctor. We also found no failings in the appointment and the actions the Practice took after the appointment. For these reasons we do not uphold the complaint.
2. We know how difficult and upsetting it has been for Mrs A and her representative and we appreciate them sharing their experience with us. We hope this report explains how we reached our view.