A practice in the Derbyshire area

5. Ms R complains on behalf of her late father, Mr S, about the care and treatment he received at the Practice in September 2021. Specifically, she complains about:

• poor communication and clinical care from a day nurse during a telephone conversation on 29 September - during the call, Mr S reported symptoms including shortness of breath, dizziness, loss of appetite, weight loss, confusion, a persistent cough, an elevated temperature and tiredness, yet Ms R says the nurse told him to take a polymerase chain reaction test (PCR test, a test which is a fast and highly accurate way to diagnose infectious diseases and genetic changes) for COVID-19, and prescribed antibiotics with no follow-up

• the day nurse did not offer Mr S a face-to-face appointment and instead had the ‘final say’ on his treatment for his reported symptoms during the telephone consultation

• the Practice failed to follow up on his reported symptoms or carry out further testing, despite Mr S being a poorly man in his late eighties – Mrs R says her father was later diagnosed in hospital (following a call to 111, who phoned an ambulance) with sepsis and pneumonia and had less than eight weeks to live, and

• poor complaint handling of the Practice - Ms R says there was an unnecessary delay in receiving a response to the complaint, and when she did receive a response, it was unsympathetic and ‘almost nasty’ despite her father’s passing.

6. Ms R says due to the Practice’s poor clinical care, Mr S experienced moderate distress and discomfort. She also says it caused distress to his family.

7. Ms R says the Practice could have diagnosed Mr S with sepsis and pneumonia sooner if it had carried out further tests when he reported his symptoms, which could have prolonged his life by several weeks.

8. In regard to the poor complaint handling, Ms R says this has caused further distress and upset to her and her family.

9. As a result of bringing the complaint to us, Ms R wants a full apology for the clinical care and complaint handling. She also wants financial compensation.

10. On 29 September 2021, Mr S had a telephone consultation with a day nurse. He reported symptoms of a dry cough, rattling in his chest, back pain and a headache. The day nurse advised him to take a PCR test and prescribed antibiotics.

11. On 2 October, Ms R phoned 111 (out-of-hours doctors) to report Mr S’s condition had deteriorated. They advised a clinician would phone back. An ambulance was called who tested Mr S and advised he should go to hospital. The hospital admitted Mr S with breathlessness on exertion. Investigations showed newly diagnosed acute myeloid leukaemia with a prognosis of less than eight weeks to live.

12. On 5 October, Ms R had a telephone conversation with the Practice Manager and raised concerns about Mr S’s consultation with the nurse.

13. On 11 October the Practice wrote to Ms R with its findings after it had received the complaint. It said, ‘an Advanced Nurse Practitioner had reviewed the consultation notes and medication prescribed and found this to be satisfactory’.

14. On 10 January 2022 the Practice responded to the complaint confirming following its complaint response on 5 October and its telephone discussion with Ms R the same day, the Practice investigated the matter and said it responded accordingly.

15. In February 2022 Mr S sadly died.

16. On 5 April 2022 we emailed the Practice, as Ms R told us she had outstanding concerns after receiving two responses (11 October and 10 January).

17. On 25 April we received a phone call from the Practice Manager. She said she would like to ask Ms R to attend a virtual meeting to discuss her complaint.

18. On 25 April we emailed Ms R asking if she would like a virtual meeting with the Practice Manager.

19. On 25 April Ms R emailed us saying she did not want to go to the meeting as she said the family will ‘never agree that Mr S was treated with the care and respect he needed and deserved’.

Care and treatment

23. Ms R says the care and treatment the Practice gave Mr S were poor. She says it could have diagnosed Mr S with sepsis and pneumonia sooner if it had carried out further tests when he reported his symptoms during the telephone consultation on 29 September, which could have prolonged his life by several weeks.

24. She says the Practice did not carry out further testing, and it wasn’t until Mr S’s family phoned 111 that he was taken to hospital and diagnosed with sepsis and pneumonia.

25. In response to the complaint, the Practice said the nurse assessed Mr S during the telephone consultation in line with the guidance in place at the time.

26. It said the nurse believed he might have been presenting symptoms of COVID-19. It said in its response it is not uncommon to get a secondary bacterial lower respiratory tract infection (infections of parts of the body involved in breathing, such as the sinuses, throat, airways or lungs) with COVID-19, so the nurse prescribed a five-day course of antibiotics (amoxicillin).

27. It said the consultation happened during the pandemic, and the advice from NHS England was to separate suspected COVID-19 cases from other patients. It said to do this, patients with symptoms suggestive of COVID-19 were either consulted by phone or in special red hubs (set up for patients who were suspected of having COVID-19 to be seen face to face), such as the one in the nearby city centre.

28. It said if Mr S had taken a PCR test and the result was negative, he could have been seen face to face at the Practice.

29. The General Medical Council Algorithm to support the triage process is quoted in the Royal College of Nursing’s ‘Remote consultations guidance under COVID-19 restrictions’ and applies to nurses and doctors. This guidance states a remote consultation should be considered when:

• the consultation is a straightforward follow-up or assessment • medical records are accessible • you have the information to treat available and are able to prescribe or arrange follow-up for prescription if necessary • the patient has capacity to understand the process.

30. The NHS’s ‘Arrangements for primary care from 19 July 2021’ says under general practice ‘all contractors should continue to offer a blended approach of face-to-face and remote appointments, with digital triage where possible’.

31. The NHS’s ‘Letter on standard operating procedures (SOP) to support restoration of general practice services’ says:

• ‘Half of all general practice appointments during the pandemic have been delivered in person, GP practices must all ensure they are offering face-to-face appointments. As the chair of the Royal College of GPs has said “once we get out of the pandemic and things return to a more normal way of living and working, we don’t want to see general practice become a totally, or even mostly, remote service”, so while the expanded use of video, online and telephone consultations can be maintained where patients find benefit from them, this should be done alongside a clear offer of appointments in person.

• Patients and clinicians have a choice of consultation mode. Patients’ input into this choice should be sought and practices should respect preferences for face-to-face care unless there are good clinical reasons to the contrary, for example the presence of COVID-19 symptoms. If proceeding remotely, the clinician should be confident that it will not have a negative impact on their ability to carry out the consultation effectively.’

32. The NICE guidance states a lower respiratory tract infection is:

‘An acute illness (present for 21 days or less), usually with cough as the main symptom, and with at least 1 other lower respiratory tract symptom (such as fever, sputum production, breathlessness, wheeze or chest discomfort or pain) and no alternative explanation (such as sinusitis or asthma). Pneumonia, acute bronchitis and exacerbation of chronic obstructive airways disease are included in this definition.’

33. The NHS pneumonia guidance says common symptoms of pneumonia include:

• a cough – which may be dry, or produce thick yellow, green, brown or blood-stained mucus (phlegm) • difficulty breathing – breathing may be rapid and shallow, and there may be a feeling of breathlessness, even when resting • rapid heartbeat • high temperature • feeling generally unwell • sweating and shivering • loss of appetite, and • chest pain – which gets worse when breathing or coughing.

34. The NICE guidance states:

‘A CRB65 score is used during a face-to-face assessment to determine if the patient is at low, intermediate, or high risk (of mortality) from CAP (community-acquired pneumonia).

Box 1 CRB65 score for mortality risk assessment in primary care

CRB65 score is calculated by giving 1 point for each of the following prognostic features: • confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time) • raised respiratory rate (30 breaths per minute or more) • low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg) • age 65 years or more.’

35. The telephone consultation Mr S had with the day nurse on 29 September 2021 was during the COVID-19 pandemic. Mr S was in his late eighties at this time. The medical records say he had never smoked and had ‘high cholesterol’.

36. We can see from the records during this consultation he reported a one-week history of the following symptoms: dry cough all the time, rattling in chest, unable to sleep, pain in back, headache, reduced diet but drinking well, and feeling short of breath but speaking in full sentences during the consultation.

37. The records state he had been doing COVID-19 lateral flow tests every other day, which were negative.

38. We can see from the records the nurse treated him for a lower respiratory tract infection with an antibiotic (amoxicillin) and advised a PCR test, to be arranged by his friend.

39. The records show the nurse advised him to contact the Practice again if he had any worsening symptoms or further concerns or if he showed no sign of improvement after the course of antibiotics. The nurse advised him to phone 111 if the surgery was closed. Our adviser said this is referred to as ‘safety-netting advice’.

40. As per the NHS Health Research Authority’s ‘Safety netting in primary care consultations’:

‘safety netting is information given to a patient or their carer during a primary care consultation about actions to take if their condition fails to improve, changes or if they have further concerns about their health in the future.

‘An example of a safety-netting statement would be “please make another appointment if your symptoms do not improve”. There is currently no set gold standard of what form safety-netting advice should take or how it should be delivered.’

41. The records show Mr S reported a short duration (one week) of respiratory symptoms. The records available do not indicate he had a chronic lung or respiratory condition. The records say he never smoked.

42. Our adviser said these symptoms indicated a lower respiratory tract infection, or community-acquired pneumonia, as per the guidance stated above.

43. Our adviser said the guidance for a CRB65 score for mortality risk assessment (see guidance above) in primary care cannot be used over the phone as it involves assessing respiratory rate, blood pressure measurements, whether the patient is confused and factors in their age.

44. However, our adviser said Mr S’s age was known during this consultation, and it could be determined over the phone that he was not confused. As per the NICE guidance, if the patient is 65 years or older, they are at intermediate risk of mortality (intermediate risk is defined in the guidance as a 1-10% mortality risk), and hospitalisation should be considered.

45. Our adviser explained the decision to recommend hospital admission for an older patient is a clinical one based on the severity of the patient’s symptoms. A further consideration would be increased COVID-19 infections in the local area and the likelihood of the patient being exposed to COVID-19 with a visit to A&E.

46. On 29 September 2021 there were 144 daily cases of COVID-19 and 50,751 total cases in the city where the Practice is based. In the nearest NHS trust, there were four daily admissions and 7,596 total admissions.

47. Regarding not offering a face-to-face appointment during the telephone consultation on 29 September 2021, we consider the care to be in line with relevant NHS guidance during this time, as the guidance states clinicians had a choice of consultation mode.

48. While we recognise the NHS guidance does say GP practices should respect patient’s preferences for face-to-face care, it says unless there are good reasons to the contrary, such as the presence of COVID-19 symptoms.

49. As the nurse believed Mr S was presenting symptoms of COVID-19 and had not yet undertaken a PCR test, we consider it appropriate the nurse did not offer a face-to-face appointment during this consultation.

50. The records also state Mr S and his friend were happy with the plan arranged during the consultation.

51. Given Mr S had the support of a friend (who was cooking for him and who was present at the time of the consultation), was able to take oral medication, and was not confused – so he would be able to follow the plan and would be able to seek further advice if he felt worse - we consider it to be within NHS guidance to recommend home care with safety-netting advice.

52. Based on the available evidence and advice received, we consider there are no signs the Practice did anything wrong. The nurse gave Mr S safety-netting advice, advising him to phone the Practice again if his symptoms did not improve and to phone 111 if the Practice was closed.

53. The symptoms Mr S reported during the telephone consultation do not indicate he had a chronic lung or respiratory condition as per the guidance. Taking this into consideration, along with the risks of COVID-19 involved with a visit to the emergency department, we can see from the records the nurse’s care and treatment was in line with the expected standard.

54. We are deeply sorry to hear of the events that surround the complaint and can only begin to imagine how distressing the experience was of Mr S being diagnosed with sepsis and pneumonia with an eight-week prognosis to live.

55. We do not consider that the care and treatment fell below the expected standard. We hope this assures Ms R the care and treatment Mr S received were appropriate and in line with guidance.

Complaint handling

56. We can see on 11 October 2021 the Practice Manager responded to Ms R’s complaint, enclosing a copy of the Practice’s complaints policy and an information leaflet setting out the processes it had followed during the investigation.

57. The letter stated, ‘Incident…daughter was not happy with the telephone consultation and subsequent medication prescribed by the On Day Service nurse… Findings: an Advanced Nurse Practitioner had reviewed the consultation notes and medication prescribed and found this to be satisfactory’.

58. In the letter the Practice directed Ms R to us if she remained unhappy. On 13 October 2021 Ms R complained to us.

59. On 10 January 2022 Ms R had a telephone discussion with the Practice Manager and the Practice wrote to Ms R confirming it had ‘investigated this matter and responded accordingly. The concerns you have raised have been investigated and actions have been taken. Therefore, this matter is now closed.’ The Practice then directed Ms R to us again if she wanted a further investigation.

60. When Ms R contacted us again, she said she had received virtually no help or assistance from the Practice. She said it took her months to get to where she was in January 2022.

61. On 5 April we emailed the Practice, as Ms R told us she had outstanding concerns after receiving two responses (11 October and 10 January). We said we could see the response letter dated 11 October referenced the findings of the investigation carried out by an Advanced Nurse Practitioner but did not give much detail or explanation about why the Practice deemed the treatment to have been satisfactory.

62. As the second response letter dated 10 January directed Ms R to us but there were still issues the Practice had not addressed, we asked the Practice to consider addressing these issues and giving its response to Ms R.

63. On 27 April the Practice Manager wrote to Ms R informing her the Practice was looking into the complaint raised in October and was meeting with the clinician involved. It said it would write to her when it could update her on the outcome.

64. On 29 April the Operations Manager at the Practice wrote to Ms R with its final response. It explained in detail how it felt the care and treatment were in line with the expected standard. It offered its sincere condolences to Ms R and her family and said it was sorry she had had to raise these concerns at what had been a difficult time.

65. It said the Practice was sorry the responses the Practice had sent had not been able to resolve her concerns and hoped this new response addressed the outstanding concerns she had. It also said if she felt a meeting would be helpful, it would be happy to arrange this for her.

66. Ms R says the seven months it took for her to get a ‘proper response’ from the Practice made the process more painful, and she thinks the Practice Manager has been ‘cruel in dragging it out’.

67. We can see how this added to an already distressing time and are sorry to hear about this.

68. When considering complaints, we look at what should have happened and what did happen to identify any gaps between the two that may indicate service failure. We also consider what the organisation has done to put things right.

69. Our ‘Principles of good complaint handling’ state:

‘Public bodies should…

• Deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards where appropriate. Resolving problems and complaints as soon as possible is best for both complainants and public bodies.

• Acknowledge the complaint and tell the complainant how long they can expect to wait to receive a reply. Public bodies should keep the complainant regularly informed about progress and the reasons for any delays, and provide a point of contact throughout the course of the complaint.’

70. The Practice’s complaints policy says:

‘We shall acknowledge your complaint within 1 working days and aim to have looked into your complaint within 10 working days of the date when you raised it with us, or advise you of why it is taking longer than this. We shall then be in a position to offer you an explanation, or a meeting with the people involved. When we look into your complaint, we shall aim to:

1. Find out what happened and what went wrong 2. Make it possible for you to discuss the problem with those concerned, if you would like this; 3. Make sure you receive an apology, where this is appropriate; 4. Identify what we can do to make sure the problem doesn’t happen again.’

71. After reviewing the timeline of events, we can see it took the Practice just over six months before it gave a detailed final response. It did send response letters within this period but did not offer any proper explanation of why the care and treatment were in line with expected standards.

72. We can understand the distress and frustration caused here by the Practice not explaining why it felt the care and treatment during the telephone consultation were appropriate.

73. Further, we have noted there was little empathy in the letter to recognise how Ms R would have been feeling during this period. We can understand how this added to what was already an extremely difficult time.

74. We have assessed the Practice’s complaints policy. We can see it did initially respond within ten working days of the complaint being raised to it. However, this response was not detailed.

75. In the final response from the Practice’s Operations Manager (which Ms R received just over six months after the initial complaint), we can see it did look into what happened and confirmed nothing had gone wrong during the consultation. However, this came after our intervention.

76. The Practice apologised to Ms R that she had had to raise concerns at a difficult time. It said it was sorry the responses received previously had not resolved her concerns.

77. The Practice Manager asked us on 25 April if Ms R would like to attend a virtual meeting to discuss her complaint with the Practice Manager. Ms R declined this offer.

78. We can see the Practice resolved the issues surrounding complaint handling in its final response letter on 29 April. It gave a detailed explanation of why it felt the care and treatment were appropriate, empathised with Ms R and apologised for the previous response letter not resolving her concerns.

79. We are satisfied the Practice rectified its initially poor complaint responses by providing a detailed response letter on 29 April and apologising.

80. We are sorry to hear of the frustration and distress caused during this time. We can understand how it made what was already an upsetting and difficult time worse for Ms R.

1. The Parliamentary and Health Service Ombudsman has carefully considered Ms R’s complaint about the care and treatment Mr S received from a practice in the Derbyshire area (the Practice) in September 2021.

2. We are very sorry to hear about the sad loss of Ms R’s father, Mr S, and for the events that surrounded the complaint. We understand this must have been a difficult and distressing time. We hope this statement gives Ms R some reassurance about what happened.

3. Based on what we have seen from the medical records, it appears the Practice’s nurse appropriately assessed Mr S in line with relevant guidelines. We have seen no signs the Practice did anything wrong in the way it responded to Mr S’s symptoms.

4. Regarding how the Practice handled the complaint, we have decided the Practice has already done enough to put right the fact that it initially handled the complaint poorly.