Issue one - concerns the Practice did not advise for Mr A to be taken to hospital
20. Mr Y complains his father was seen remotely by a General Practitioner (GP) from the Practice on 13 April 2020. He complains his father’s condition at the time should have warranted the GP advising the home to transfer his father to the hospital.
21. He complains this did not happen and on 18 April, Mr A was rushed to hospital. He says, following this his father died on 20 April 2020.
22. Mr Y raises concerns that if his father was taken to hospital on 13 April 2020, his condition would not have deteriorated and he would not have died. We appreciate the worry and distress these events have caused.
23. In the Practice’s response dated 17 August 2020, it explains during the 13 April consultation, the GP advised staff at the Nursing Home that if Mr A’s symptoms continued or he got worse then he should be taken to the emergency department. The Practice says in error the GP failed to document this part of the advice in her consultation notes.
24. Having reviewed the records, we have seen no evidence of the GP advising the Nursing Home to transfer Mr A to hospital if his symptoms persisted. We have also obtained a statement from the nurse at the Nursing Home that the GP spoke to during the consultation. The nurse has no recollection of this advice being provided.
25. Based on the evidence we have seen, we find that the GP did not advise staff at the Nursing Home to transfer Mr A to hospital on 13 April 2020.
26. We have considered if this advice should have been given, based on the symptoms Mr A was presenting at the time of the consultation.
27. The GP records document the 13 April 2020 consultation as follows: ‘Routine virtual ward round febrile urine positive multi resistant organism, for fosphomycin currently taking ciprofloxacin and coughing, has had UTI for 6 days and still febrile. Seen face to face on video call video consultation, lying in bed not up at the moment’
28. We have also reviewed the records from the Nursing Home following the same consultation. It is noted: ‘Mr A was still having temperature from time to time. He appears lethargic and weak. Was seen by the GP. Will be prescribing Fosfomycin, to stop his current antibiotics as the bacteria looks like resistant as well. To refer back if needed’.
29. Having reviewed both sets of notes, we consider the Practice’s record keeping to not be in line with GMC guidance, which in section ‘develop and maintain your professional performance’ states: ‘Record your work clearly, accurately and legibly Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.
Clinical records should include: • relevant clinical findings • The decisions made and actions agreed, and who is making the decisions and agreeing the actions • the information given to patients • any drugs prescribed or other investigation or treatment • who is making the record and when.’
30. We find the GP did not record all of the relevant clinical findings, which included the observations that Mr A was lethargic and weak, was advised to stop his current antibiotics, and the advice given to refer back to the GP if needed. Therefore, we find the record keeping was not in line with GMC guidance.
31. Although we find failings in the Practice’s record keeping, Mr Y raises concerns that if his father was transferred to hospital on 13 April 2020, his father’s health would not have deteriorated.
32. We have therefore considered if it was appropriate for Mr A to be transferred to hospital on the 13 April 2020, based on the symptoms he was presenting with.
33. It is important to note that the appointment on 13 April 2020 was not the first consultation between Mr A and the Practice. We have reviewed the previous consultations to see if there were any indications of Mr A’s condition deteriorating, which would warrant a hospital admission on or prior to 13 April 2020.
34. From the GP and Nursing Home records, we understand Mr A was seen on 2 April as he had a cough, temperature of 37.5 and diarrhoea. It is recorded that he was eating and drinking and had no shortness of breath and could complete a full sentence in one breath. A diagnosis of a viral infection is recorded, and the GP advised Mr A to isolate for seven days.
35. Following a urine sample collected on 3 April, another consultation took place on 9 April 2020. It was noted that Mr A had a UTI, he had a poor appetite and felt unwell. He had a fever of 37.2. The GP advised to provide another urine sample and if the infection was still there, he would need an Intravenous drip (IV). He was advised to drink plenty of fluids.
36. An IV is used to administer fluid and medications to a patient.
37. On the 10 April, the GP records evidence Mr A had a temperature of 38.4 and the Nursing Home staff advised he had been very irritable. He declined providing a urine sample and did not want to go to bed. The GP notes state that there was no change in his cough, he was alert and comfortable eating his lunch. It is recorded that there were no respiratory symptoms to suggest COVID-19. The GP advised to trial Ciprofloxacin and if there was no improvement it may be appropriate for him to have an IV.
38. Ciprofloxacin is an antibiotic used to treat different types of bacterial infections.
39. The next consultation takes place on 13 April 2020, which is the consultation Mr Y specifically raises concerns about.
40. As explained above, it is noted during this consultation Mr A had a cough, and there was no improvement in his temperature.
41. At the time of Mr A’s consultations in April 2020, COVID-19 was at its peak and at the time there was no national guidance in place to advise when patients should be hospitalised.
42. However, a month later on 18 May 2020, the Department of Health and Social Care provided advice that all individuals should isolate if they develop a new or continuous cough, fever or the loss or change in the normal sense of smell. Therefore, based on this there are no indications that Mr A’s condition warranted him being transferred to hospital, but it was appropriate for him to isolate, which was the advice the GP provided.
43. We can also see in March 2020, a letter was sent from the Chief Executive Officer of the NHS to all NHS organisations. Although the letter does not include specific triggers for when a person should be hospitalised, it makes clear that organisations should ‘prepare for, and respond to, the anticipated large numbers of COVID-19 patients who will need respiratory support’.
44. We can see from the records, at no point during the April 2020 consultations, in particular the complained of 13 April consultation, was it noted that Mr A suffered from respiratory difficulties, including shortness of breath.
45. Therefore, based on the above we find that with the symptoms Mr A presented with, which were a cough, temperature, and a poor appetite, he did not need to be transferred to hospital on 13 April.
46. We can also see from the records, even after 13 April, there is evidence that Mr A’s condition remained stable. We can see a consultation took place on 16 April due to a complaint of broken skin. It is recorded in this consultation that ‘patient has no symptoms of COVID-19 nor have they been tested high temperature’.
47. We have also reviewed the Nursing Home records, which shows evidence of Mr A’s stability. Some examples include: • 14 April 2020- ‘Mr A served with lunch of mash and salmon, soup, yoghurt, and cup of drink. He tolerated a cup of drink and few spoons of soup’, ‘passed urine’, ‘hot drink given’, ‘ate half a small portion of soup, cheese sandwich, yoghurt, and juice’.
• 15 April 2020- ‘Jewellery worn’ ‘bowels opened’, ‘passed urine’, ‘Mr A had a meal at Breakfast. Ate 1/4 of a small portion of Porridge, scrambled egg, bread, tea with thickener’
48. We consider the GP acted in line with GMC guidance ‘domain 1: knowledge skills and performance’ which states in section 15: ‘You must provide a good standard of Practice and care. If you assess, diagnose, or treat patients, 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 • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs’.
49. The Practice adequately assessed Mr A’s condition including his fever, cough, and indications of UTI. It accordingly requested urine samples.
50. We understand the reason Mr A was transferred to the hospital on 18 April 2020 was due to him collapsing. An ambulance was called, and he was transferred to hospital. Based on the evidence we have seen, the GP’s decision not to transfer him to hospital on the 13 April, or any time prior to his deteriorating of health on 18 April 2020, was in line with the relevant guidance.
51. In addition, Mr A was in a clinical setting in the care of qualified nursing staff, therefore should the staff have had any concerns that a transfer to hospital was necessary they also had the option to call the hospital or an ambulance at any time after the 13 April 2020.
52. Based on the evidence we have seen, we find no failings in the Practice not advising the Nursing Home that Mr A should have been transferred to hospital following the consultation on the 13 April 2020.
Issue two - concerns the Practice did not keep Mr Y informed of his father’s health
53. Mr Y complains the Practice failed to inform him of his father’s deteriorating health, specifically following the 13 April consultation.
54. The Practice states in its response to us dated 15 July 2021: ‘It is not standard Practice to speak to the family of a patient after a contact with the patient at a care home. The care home staff would normally communicate any actions that the doctor had taken with the family members. Mr A had not expressed a wish for me to discuss his conditions with you, therefore I could not see a reason to do this’.
55. The GMC states in Domain 3: Communication partnership and teamwork in section ‘communicate effectively’: • 31. You must listen to patients, take account of their views, and respond honestly to their questions.
• 32. You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.
• 33.You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
• 34.When you are on duty you must be readily accessible to patients and colleagues seeking information, advice, or support.’
56. We understand there are no national guidelines in place which confirms whether the Practice or the Nursing Home should speak to a person’s family. However, our advisor tells us in practice, communication with the family would be a combination of the GP and the Nursing Home.
57. We find that as Mr A was in the care of the Nursing Home and the GP was liaising with the nurse during the 13 April consultation, it is reasonable that any updates or actions from the consultation were communicated to Mr A’s family by the Nursing Home.
58. However, more importantly from the records, we can see no evidence of Mr A requesting for information to be shared with Mr Y.
59. From the evidence, there are no concerns that Mr A lacked capacity and therefore he was able to make his own decision about who his information can be shared with.
60. Based on the above, we find the Practice acted in line with GMC guidance as it took into account Mr A’s wishes and views.
61. Although we acknowledge Mr Y’s concerns that not being updated caused him distress, we find there was no obligation on the GP to contact him and update him about his father’s condition.
Issue three - concerns about the Practice’s record keeping
62. Mr Y raises concerns about the Practice record keeping. Specifically, he tells us that the Practice failed to record information about whether Mr A was advised to be transferred to hospital in the 13 April consultation.
63. As explained above, the Practice has acknowledged failings in its response dated 15 July 2021. It says ‘On reflection, I think I could improve my note keeping of that entry’ (referring to the 13 April 2020 consultation). It goes onto explain that the GP advised the Nursing Home if the symptoms worsened Mr A should be taken to hospital or referred to the Practice. The response says ‘unfortunately, there is no record of that part of the conversation. I have learnt from this event that I should improve the content of my note keeping… I sincerely apologise’.
64. As an outcome to his complaint Mr Y has requested explanations for why the information was not recorded. The GP states in her further response dated 15 July 2021 that she focused her record keeping on recording the correct course of antibiotics. The response goes on to explain: ‘Although I consider it was appropriate that I focused on the medication, I accept that I should not be omitting recording any parts of the conversation. I will be mindful of this in future’.
65. We find it is reasonable that a lack of adequate record keeping caused Mr Y distress. However, we cannot link this to Mr A’s deterioration or death.
66. We consider the Practice’s actions of acknowledging failings, apologising, and improving practice for the future is in line with our Principles for Remedy which state: ‘It can benefit the public body as well as the complainant, by showing its willingness to: • acknowledge when things have gone wrong • accept responsibility • learn from its maladministration or poor service • put things right.’
67. We find the Practice’s actions already puts right the distress caused to Mr Y. We therefore do not uphold this part of the complaint.
Conclusion
68. Based on the evidence we have seen, we find the Practice has taken appropriate action and has also put right the distress it caused to Mr Y. We therefore do bynot uphold the complaint.
69. We are very sorry to hear of the loss of Mr A and understand what an upsetting time this must have been for Mr Y and his family.