Blood pressure monitoring
28. Mr L says the GP left too long between measuring his father’s blood pressure.
29. The NICE hypertension guidance sets out how doctors should look after people with high blood pressure. It says GPs should ‘provide an annual review of care for adults with hypertension to monitor blood pressure, provide people with support, and discuss their lifestyle, symptoms and medication’.
30. The GP last recorded Mr T’s blood pressure in January 2019 and it was 120/70 mmHg. NICE says an elevated blood pressure is over 140/90 mmHg. Therefore, we believe Mr T’s blood pressure was under control at this point and managed effectively.
31. In line with NICE guidance the GP should have monitored Mr T’s blood pressure again sometime around January 2020, but this did not happen. In the GP’s complaint response, they explained they measured his blood pressure in November 2020, but there is no record of this. Notes show the GP regularly gave lifestyle advice concerning Mr T’s use of the gym and alcohol intake.
32. The fact the GP did not take an annual blood pressure reading in 2020 fell so far below the applicable standard it amounted to a failing.
33. Where we find a failing, we then look at whether it harmed the person concerned. We have therefore considered the impact Mr L has told us about. He says the GP’s actions meant his father’s blood pressure became so uncontrolled it caused the stroke that resulted in his death.
34. To reach a view on this we looked at Mr T’s medical records and post-mortem report. We also spoke to a cardiology adviser to understand the circumstances of Mr T’s death.
35. Mr T had had hypertension for 25 years and it was managed in the same way throughout this time. The fact he had a stroke could indicate the management had stopped being effective. We acknowledge Mr L says the management changed when the GP altered Mr T’s prescription on 27 October 2020. However, we are satisfied the drug Mr T was taking remained the same, and we have given a detailed explanation of this later in this report.
36. The post-mortem report explained Mr T had died due to an intracerebral haemorrhage and ‘hypertension is a significant risk factor’. It is true high blood pressure increases the risk of strokes. However, there is not enough evidence for us to say whether his blood pressure was raised at the time of his death or even whether this was likely. Our adviser said the evidence we have seen suggests his blood pressure was not dangerously high.
37. We also cannot ignore he had other significant risk factors that contributed to the possibility of a stroke. Mr T had a body mass index of 34, which means he was obese. He drank 74 units of alcohol per week, which is significantly higher than the limit of 14 units recommended by the NHS. The impact of alcohol on his health was demonstrated byenlarged red blood cells and a larger than normal liver. This is no criticism of Mr T. We simply must balance out the relevant factors.
38. We have weighed up the available evidence from the medical records, the information from Mr L and the information from the advisers. Given Mr T’s hypertension was managed consistently for so long, it is very unlikely it became so uncontrolled after January 2019 that it resulted in a stroke. Instead, it is likely the other risk factors overwhelmingly contributed to his unexpected death.
39. We acknowledge how unsatisfactory this is likely to feel for Mr L. In reaching this decision we have balanced his account with the medical evidence and expert advice. Having done so we cannot link the failure to check Mr T’s blood pressure in early 2020 to the main impact Mr L has told us about.
40. Although we believe the failure to monitor his blood pressure in 2020 had no impact on Mr T’s health, the knowledge something went wrong was exceptionally concerning for Mr L. This concern was not solely due to the blood pressure monitoring. Mr L was also worried about other aspects of Mr T’s care, which we have addressed below.
41. We next looked at what the Practice has done to put this right. In its complaint response the Practice admits the GP made a mistake when monitoring Mr T’s blood pressure. It said sorry for what happened and it was working to improve how it communicates with patients about routine monitoring. This apology did not fully acknowledge the emotional impact Mr L experienced.
Change of medication
42. Mr L complains on 27 October 2020 his father’s GP changed his medication from Securon SR to the generic alternative, verapamil. He says although the two drugs his father had were similar, they were not the same. He says his father’s spastic paraplegia and suspected liver problems meant it was not right to change the prescription without more information and monitoring.
43. The BNF gives prescribing guidelines for verapamil. It instructs doctors to be cautious when giving it to patients with liver disease or neuromuscular disorders. We fully understand why Mr L had concerns about this.
44. The leaflet that comes with verapamil reiterates these precautions. It warns doctors prescribing to patients with liver disease that ‘caution should be exercised and careful patient monitoring is recommended’. It also says doctors should be cautious in the presence of diseases where neuromuscular transmission is affected (like Mr T’s spastic paraplegia). This does not mean it is wrong to prescribe verapamil to patients with neuromuscular disorders, but doctors should be aware of the risks when doing so.
45. We have also considered the GMC’s ‘Good Medical Practice’, which sets out what it means to be a good doctor. It says doctors should consult colleagues where appropriate and work collaboratively with them.
46. In the GP’s complaint response to Mr L, they explained Mr T could not get hold of his old prescription of Securon SR. To make sure his hypertension management remained the same they changed his prescription to a generic alternative. The replacement Vera-Til SR tablets the pharmacist gave were effectively the same drug with a different manufacturer and different ‘filler material’. They explained this would not have caused any problems for Mr T as the active ingredient and the dose did not change.
47. Our GP adviser agrees this explanation is accurate. They also noted there likely were supply problems at this time, and it was important to continue managing Mr T’s hypertension effectively with medication.
48. Mr L is correct that guidance says doctors should be cautious when prescribing verapamil to people with liver problems. One week after the prescription change Mr T had a blood test that checked how well his liver was working. It showed he did not have liver disease, and there was no reason to withhold verapamil for this reason.
49. Similarly, the guidance does warn about prescribing verapamil to patients with neuromuscular disorders. Mr T had been taking verapamil since 1996 with no problems. He saw a consultant neurologist on 20 October 2011 about his spastic paraplegia. The consultant knew Mr T was taking Securon SR and agreed to leave it unchanged.
50. A GP does not have knowledge equal to a consultant who specialises in a particular area of medicine, such as neurology. Therefore, the GP continued prescribing in line with the opinion of a specially qualified colleague.
51. We are satisfied Securon SR and Vera-Til SR are effectively the same drug, and the change was appropriate. The guidance for verapamil does advise caution in certain circumstances, and the GP demonstrated this appropriately.
Advice on returning to the gym
52. Mr L complains the GP did not give his father the right advice about returning to the gym on 29 September 2020. He says his father complained of pain and shortness of breath and the GP told him to return to the gym but do less.
53. He says the GP should not have given this advice without first measuring Mr T’s blood pressure, especially after they changed his prescription. Mr L says his father had a break from the gym and returned for the first time on 29 December. Mr T sadly died that night.
54. The NICE hypertension guidance says doctors should give appropriate lifestyle advice to people with high blood pressure. We know Mr T visited the gym to help manage the symptoms of his spastic paraplegia. However, the NHS website explains exercise can also be used to manage hypertension effectively.
55. Our GP adviser explained exercise is an appropriate way to manage raised blood pressure, and this advice was appropriate for Mr T too. Although blood pressure is temporarily elevated during exercise, it generally remains lower compared to someone with hypertension who does not exercise.
56. We also understand that if Mr T’s exercise was going to cause a problem stroke symptoms would happen during exercise when the blood pressure was raised. Mr T died at home rather than in the gym.
57. As explained above, it was wrong the GP did not measure Mr T’s blood pressure in January 2020 or at any point after that. However, given exercise is a recommended way of controlling hypertension, we believe it was appropriate for the GP to encourage Mr T to continue visiting the gym regardless.
58. Also, there is no record in the notes to say Mr T was concerned about his health after the GP changed his prescription or he had stopped going to the gym and planned to return. Based on the information the GP had when Mr T went to the gym on 29 December, we are satisfied they acted correctly. We hope this gives Mr L at least some peace of mind.
Complaint handling – written complaint responses
59. Mr L complains the Practice did not handle his complaints in January and May 2020 effectively. He says its responses gave him further doubts about how it cared for his father.
60. The Practice’s ‘Complaints Information’ leaflet from the time sets out how it handles complaints. It says the Practice will, ‘aim to: • Find out what happened and what went wrong.
• Make it possible for you to discuss the problem with those concerned if you would like this.
• Make sure you receive an apology, where this is appropriate.
• Identify what we can do to make sure the problem does not happen again.
• Write to you on completion of a complaint investigation explaining how it has been resolved, what appropriate action has been taken and advising you of your right to take the matter to the Health Services Ombudsman if you are still unhappy.’
As the Practice’s approach is largely in line with the NHS complaints guidance and our Principles of Good Complaint Handling, it is an appropriate standard to use.
61. Our Principles of Good Complaint Handling say organisations should be open and honest when accounting for their actions. When things do go wrong, they should explain why and say what they will do to put matters right as soon as possible.
62. We have spoken to Mr L and the Practice about what happened. We have also considered their correspondence and the Practice’s complaint responses dated 25 February and 21 August 2021.
63. Mr L first complained to the Practice on 13 January. He was concerned about the change in his father’s medication and the GP’s advice about returning to the gym.
64. The GP’s response set out a timeline of his father’s medical history. It explained their decision to alter the prescription to a generic drug brand. They told Mr L his father had already returned to the gym before visiting the Practice and had done so with no problems. The GP admitted they failed to check Mr T’s blood pressure when they should have, but COVID-19 prevented them from doing so. The GP apologised for this and said they were aware of the problem and thinking about ways to stop it happening again.
65. Mr L remained unhappy and wrote to the Practice again on 10 May. He thanked the Practice for its response but explained that before taking his complaint further he felt it best to speak to the Practice manager or doctor before doing so. He gave details of his original complaint that he felt went unanswered, provided some more guidance on what he believed should have happened and raised a complaint about how the GP had investigated his father’s enlarged red blood cells.
66. The GP replied in a letter dated 2 August. They gave further details about Mr T’s prescription and their investigation of his enlarged red blood cells.
67. We know it was worrying for Mr L to learn the GP did not monitor his father’s blood pressure in the way he expected, and rightly so. We also know how unhappy he was that, in his eyes, the responses did not properly resolve his complaint.
68. Having compared the Practice’s responses to the relevant guidance, we consider it was good complaint handling to acknowledge it had made mistakes in monitoring Mr T’s blood pressure. The responses also properly explained what had happened and why.
Complaint handling – complaint meeting
69. Mr L also complains he asked to meet with staff and discuss his complaint in his email dated 10 May, but they refused to do so. He also told us he contacted the Practice by phone on three occasions to try to arrange a meeting but it did not answer his calls or return his messages.
70. Our Principles of Good Complaint Handling say organisations should have a customer-focused complaint process that accounts for the needs of the individual. They should respond to correspondence flexibly and adjust to the circumstances of the individual case.
71. We have read Mr L’s email from 10 May. It is not strictly true he asked to meet with staff. Instead, he explained he wanted to speak to staff and then set out his further complaint. He ended the letter by saying he was looking forward to their response.
72. Having read the email, it does not obviously seem like a face-to-face meeting request. Instead, the Practice treated it like another written complaint and responded in writing. Although it might have been better if the Practice had clarified things with Mr L at that point, at this stage we think it was a reasonable approach to take.
73. To understand how the Practice handled Mr L’s phone calls, we spoke to the Practice manager. They explained there are no saved messages from the time and do not remember the calls Mr L has told us about. Given the length of time that has passed since his complaint we would not expect it to have a record or remember them.
74. As we have two competing versions of events, we have weighed up the likelihoods involved. Given this experience would be an unusual and memorable one for Mr L we consider it is more likely than not the calls did happen. If the Practice had spoken to Mr L over the phone, it is likely he would have asked for the face-to-face meeting at this point. The Practice did not respond as it should have done, and we find this was a failing.
75. Mr L told us he feels frustrated his requests for a meeting went unanswered. He lost faith in the care the Practice provides, and this meant he changed to a different GP surgery.
76. We cannot know for sure whether a face-to-face meeting would have affected Mr L’s choice to change practice. This is because it is unlikely staff would have told him anything different to the letter it sent dated 2 August. In turn, he would likely have left the meeting feeling much the same way. However, a conversation in person would likely have prevented his frustration from trying to arrange a meeting unsuccessfully. So, although we did not find the poor complaint handling had the full impact claimed, we agree it negatively impacted Mr L.