Mrs E's assessment
18. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any signs that something went wrong.
19. Section 6 of NMC guidance states: ‘nurses must assess need and deliver or advise on treatment or give help (including preventative or rehabilitative care) without too much delay and to the best of their abilities, on the basis of the best evidence available and best practice.’
20. Section 10 of NMC guidance states nurses must: ‘Keep clear and accurate records relevant to your practice. This applies to the records that are relevant to your scope of practice. It includes but is not limited to patient records. To achieve this, you must:
• 10.1 complete records at the time or as soon as possible after an event, recording if the notes are written some time after the event • 10.3 complete records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements • 10.4 attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation.’
21. NHS guidance ‘Symptoms of a heart attack’ says the symptoms of a heart attack can include:
• chest pain – a feeling of pressure, heaviness, tightness or squeezing across your chest • pain in other parts of the body – it can feel as if the pain is spreading from your chest to your arms (usually the left arm, but it can affect both arms), jaw, neck, back and tummy • feeling lightheaded or dizzy • sweating • shortness of breath • feeling sick (nausea) or being sick (vomiting) • an overwhelming feeling of anxiety (similar to a panic attack) • coughing or wheezing.
22. Mr E says the ANP failed to correctly assess Mrs E’s symptoms and identify she had signs of a heart attack instead of an infection, and did not refer her for, or provide, appropriate treatment.
23. Mr E says the ANP did not provide advice about what Mrs E should do if the chest and back pain continued. He says the ANP did not explain any red flag warnings Mrs E should watch out for. These red flag symptoms include symptoms such as pain in other parts of the body (including left arm, jaw, neck, back and tummy), feeling lightheaded or dizzy, or an overwhelming feeling of anxiety.
24. Mr E also says key information about Mrs E’s symptoms and clinical history in her medical records were not recorded accurately. He says he believes these details could have been added after the consultation took place.
25. The Practice response explained it reviewed the ANP’s actions. It said it did not believe anything went wrong with the actions staff took, the procedures they followed or the medical care they gave to Mrs E.
26. The Practice said the ANP had examined and diagnosed Mrs E’s symptoms correctly and believed red flag advice had been discussed for if her symptoms continued. The Practice said the consultation had been documented accurately in Mrs E’s medical records. An audit trail has shown no amendments were made to the notes following the consultation.
27. The Practice also said it held a Significant Events Meeting with its clinicians, who agreed they would not have managed the presenting factors and symptoms any differently than the ANP.
28. Our adviser explained the nurse who saw Mrs E was an ANP who is educated to Master’s degree level in advanced clinical practice. ANPs can apply professional knowledge to patient care and clinical decision-making. This is an important distinction to make, as the training and experience for nursing practitioners varies widely, whereas ANPs undertake formal, recognised training and must meet the standards set while working at this advanced level.
29. We can see from the records the ANP assessed and documented Mrs E’s symptoms and physical observations. The ANP indicated Mrs E was suffering from only two potential cardiac symptoms: her tight chest and a feeling of nausea/vomiting.
30. The records show the ANP concluded Mrs E had costochondritis/costochondral joint syndrome (a condition where there is inflammation of the connective tissue where the ribs attach to the breastbone). Symptoms include dull to sharp pain at the front of the chest wall that may radiate to the back or abdomen.
31. We can see the ANP made a diagnosis, gave advice about pain relief and recommended calling Out of Hours on 111 to discuss red flag warning signs if there were any concerns at all. This is documented in Mrs E’s records.
32. The records indicate documentation of the consultation was in line with section 10 of NMC guidance.
33. In our adviser’s opinion, the ANP was sufficiently qualified and experienced to assess Mrs E’s symptoms and identify the cause. Our adviser said, based on the documented history, symptoms, signs and assessment, there were no signs the patient needed further investigation.
34. In our view, the records, symptoms, signs and assessment indicate the ANP made an appropriate diagnosis of costochondritis. The symptoms Mrs E reported appeared to match the symptoms listed in the NHS guidance for costochondritis.
35. We recognise Mr E does not recall ‘red warning’ advice being given. However, the notes about the consultation and advice given are part of a detailed and comprehensive entry made at the time of the appointment. On the balance of probability, this would indicate the ANP gave this advice.
36. In summary, it appears the ANP had access to and considered Mrs E’s previous medical history and presenting symptoms and advised on red flag warnings in line with the above guidance. The ANP assessed Mrs E’s symptoms, reached a diagnosis based on her assessment and recorded her symptoms, signs and assessment, all in line with the NMC guidance.
37. We recognise the difficult time Mr E and his family went through and the impact this had on them. We hope our explanation helps Mr E to gain closure and reassurance about what happened.
Mrs E’s medical condition not being recorded accurately
38. Mr E says the receptionist failed to record Mrs E’s medical condition correctly as chest and back pain, breathing problems and feeling sick as advised, and instead recorded chest and back infection.
39. Mr E says this meant Mrs E missed an opportunity to be reviewed by a doctor and the Practice failed to follow the correct procedure for handling requests for urgent medical attention.
40. The Practice’s response states the receptionist documented ‘back and chest infection’ within the appointment slot. This does not correspond with the symptoms Mr E says he told the receptionist Mrs E had. Mr E says the symptoms reported to the receptionist were chest and back pain, breathing problems and feeling sick.
41. We do not have a recording of the call between Mr E and the receptionist, and there is no documented summary of the call taken by the receptionist at the time of the events. We have therefore considered the information from the Practice’s response and the information provided by Mr E.
42. We are unable to confirm the details of the conversation that took place between Mr E and the receptionist, but can see a patient with a suspected infection would still be allocated a routine ‘on the day’ appointment in line with the Practice’s triage pathway, which states:
‘ROUTINE – List in visit request schedule on the Appointments screen – Advise the patient the doctor will make contact between morning and afternoon surgeries (11.15–4.00) – Advise the patient to call back if the situation is worsening or concern is growing.’
43. We can see Mrs E was given an appointment that day within 30 minutes of the telephone call being made and, despite the discrepancy during the call with the receptionist, the symptoms Mr E says were of concern were still looked at as part of the ANP’s assessment.
44. Mr E believes that a doctor rather than the ANP would have seen Mrs E had the receptionist noted Mrs E’s presenting symptoms differently. While this did not happen, although the Practice's pathway says a doctor will call back, the Practice offered an earlier appointment with the ANP.
45. As mentioned, we can see the ANP had the correct training and experience to carry out this assessment, and appeared to do so in line with NMC guidance. We have seen no indications of failings in respect of the ANP’s assessment.
46. While we cannot reconcile the discrepancy between the Practice and Mr E’s account of the symptoms, we can see from the information provided Mrs E had an adequate assessment, which included her breathing and reports of pain and nausea.
47. As noted above, our adviser was satisfied the ANP assessed Mrs E’s symptoms correctly and reached an appropriate diagnosis based on that assessment.
48. We recognise Mr E’s concern Mrs E missed an opportunity to be reviewed by a doctor. Our view is that, although we are unable to confirm the details of the conversation that took place between Mr E and the receptionist, we can see Mrs E went on to have an assessment in line with the NMC guidance. It appears the ANP’s diagnosis and advice were in line with the Practice pathway with no need to refer Mrs E to a doctor.
The Practice failed to respond accurately
49. Mr E says the Practice failed to respond accurately, as its response was based on inaccurate and incomplete information its staff had recorded.
50. Section 10 of the NMC guidance states: ‘Keep clear and accurate records relevant to your practice. This applies to the records that are relevant to your scope of practice. It includes but is not limited to patient records. To achieve this, you must:
• 10.1 complete records at the time or as soon as possible after an event, recording if the notes are written some time after the event • 10.3 complete records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements • 10.4 attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation.’
51. Our principles state that, to put things right, organisations should be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations and reasons for their decisions.
52. A review of the provided documents shows the ANP made clear, detailed records at the time of the consultation, providing an audit trail of when the entries were made, and no amendments were made following the consultation.
53. We can see the Practice accepted Mr E had a different account of what happened and explained the recollection and discrepancies between each party, compared to the medical records made at the time.
54. We can see the Practice has documented it discussed in depth the consultation with the ANP and held a Significant Events Meeting in February 2020 with its clinicians. The clinicians concluded the actions the ANP took were correct.
55. In our view, based on the Practice’s written responses and actions, the Practice took the complaint seriously.
56. We have seen the Practice responded to the concerns raised by Mr E. In our view, the Practice appears to have provided an accurate, clear explanation of who was involved in responding to Mr E’s complaint and how it reached its decision.
57. We have seen the ANP clearly and accurately recorded Mrs E’s symptoms, physical observations, previous medical conditions, diagnosis, treatment and advice given at the time of the examination. Our adviser thinks the documentation of the consultation was in line with section 10 of the NMC code.
58. We can see the Practice took the time to reply to further correspondence from Mr E, providing further acknowledgement of the impact that Mr E described. We can also see the Practice considered Mr E being unhappy with the outcome before issuing its final response. This is in line with our principles.
59. Our view is the documents and records used to aid the investigation of Mr E’s complaint with the Practice were detailed and robust enough to provide a thorough response to his complaint. We are satisfied the Practice provided a complete and accurate response to Mr E’s complaint.
60. We recognise Mr E was concerned the information recorded by staff was inaccurate and incomplete. We were sorry to hear about the distress the above events caused to Mr E and his family. We hope this gives Mr E some reassurance that the Practice investigated the complaint following the correct process and the documents used were accurate and complete.