Telephone consultations
14. Before we decide to conduct a detailed investigation of a complaint we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have not found any signs something went wrong in the care the Practice gave Mr R.
15. We first considered Mrs R’s concerns the Practice did not assess her husband, Mr R, face to face or refer him to hospital when he contacted them several times between 31 March and his death in April 2020.
16. Mr R first spoke to the Practice on 31 March. He reported his symptoms and the GP thought they were caused by a flare-up of his sarcoidosis.
17. NHS Choices on sarcoidosis says: ‘If treatment is recommended, prednisolone steroid tablets are usually used. This medication is the most effective treatment for sarcoidosis, helping to relieve symptoms and prevent damage to affected organs by reducing inflammation and preventing scarring.’
18. GMC guidance says doctors ‘must provide a good standard of practice and care. If [they] assess, diagnose or treat patients, [they] must: 1. 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 2. promptly provide or arrange suitable advice, investigations or treatment where necessary 3. refer a patient to another practitioner when this serves the patient’s needs.’
19. Our adviser said it was appropriate for the GP to prescribe Mr R steroids because he was suffering from a known condition and the symptoms he was experiencing were consistent with a flare-up of sarcoidosis. The Practice appropriately prescribed prednisolone to Mr R in line with NHS guidance.
20. NHS England guidance at this time said GP practices should adopt remote triage as standard practice to initially assess patients. They should deliver care and treatment remotely when possible and appropriate, based on clinical judgement, as well as home visits if clinically necessary.
21. Our adviser said the decision to do a further face-to-face assessment of a patient would have been a matter of clinical judgement. They explained as Mr R was experiencing a flare-up of a known condition it was appropriate for the Practice to prescribe treatment without a face-to-face appointment. We consider the Practice carried out an assessment of Mr R’s condition, taking into account his symptoms and medical history. This is in line with GMC guidance.
22. Mr R spoke to a GP a second time on 3 April. He told the GP he felt as if his mind was racing and he had insomnia. The NHS Choices website listed these as side effects of prednisolone.
23. Our adviser explained as there was no suggestion at this point Mr R’s chest symptoms had worsened, and because he was complaining of recognised steroid side effects, it was reasonable to reduce the medication. Our adviser said it was appropriate for this interaction to be through a telephone consultation. The source of Mr R’s symptoms were explainable as a side effect of his medication so no further investigations or assessment were thought to be necessary.
24. Mr R spoke with a GP at the Practice again on 7 April. He reported having swollen legs, insomnia and flecks of blood in his sputum. He said his cough was 80% better. He did not report shortness of breath.
25. Our adviser explained swollen legs can be a side effect of prednisolone, and as Mr R had reported his respiratory symptoms had improved, it was reasonable for the Practice to stop the steroids. The GP advised Mr R to elevate his legs and told him to contact the Practice again if the problem persisted or his condition deteriorated.
26. Our adviser said the GP could have considered a face-to-face assessment as this was the third telephone call for the same period of care/problem. But there is no national guidance on this.
27. Our adviser explained Mr R’s respiratory symptoms had improved by this point and his other symptoms could be explained by the steroids. Mr R had a rare condition and there was nothing in the days leading to his death to suggest his heart was affected. Our adviser said because Mr R was in his late fifties, with no history of heart disease, it was unlikely a GP would suspect heart failure due to sarcoidosis. Also, Mr R did not have shortness of breath, a key symptom of heart failure.
28. If Mr R had been seen face to face on 7 April, or if the GP had suspected his symptoms were related to heart failure, our adviser has said the GP would probably have arranged a blood test or made an urgent respiratory referral. It is very unlikely either of these would have taken place before Mr R sadly died.
29. Mrs R has told us she is specifically concerned the GP did not recognise Mr R’s swollen legs meant he was suffering from heart failure and his ‘yellowish colour’ showed his kidneys and liver were not working properly.
30. We have looked at Mr R’s medical records and the GP noted Mr R said he was ‘pale’. We asked our adviser if either looking ‘pale’ or ‘yellowish in colour’ should have led to the GP making a different diagnosis or suspecting Mr R was suffering from heart failure.
31. Our adviser explained a change in colour is a non-specific sign someone is unwell. They said if the GP had considered Mr R was ‘yellowish’ in colour it is not likely this would have led them to suspect heart disease. The GP did note in Mr R’s medical records he had reported looking ‘pale’. This is in line with GMC guidance as part of the GP’s assessment of Mr R’s condition.
32. Following careful consideration of the available evidence, the advice we have received and national guidance relevant to this case, we have not seen any signs the Practice got something wrong in the care it gave Mr R between 31 March and 7 April.
33. We are truly sorry to hear about Mr R’s death and the significant impact this has had on Mrs R. We know Mrs R will be disappointed with our decision to take no further action. We hope our work can give her some further explanation about the care her husband received.