A practice in the Calderdale area

4. Mrs A complains about the care and treatment her mother, Mrs H, received from the Practice. She says:

• Mrs H was diagnosed multiple times over the phone, resulting in little or no effect • the communication between the Practice and its patients at the surgery is poor • the Practice’s failure to diagnose Mrs H’s condition quickly enough led to Mrs H’s death.

5. Mrs A says Mrs H’s primary cause of death was an infection in her liver (biliary), which had turned into sepsis. She says the lack of care from her GP was the root cause of this as the infection had gone undiagnosed for a long period of time.

6. Mrs A says she would like the Practice to learn lessons to improve its communication with families so that other patients and relatives do not go through the same experience as she has. Mrs A would also like a face-to-face meeting with the Practice to get further answers to her concerns.

7. In October 2020, Mrs H became unwell and complained of severe pains in her stomach and back.

8. On 17 June 2021, a telephone consultation took place between Mrs H and the Practice doctor. Mrs H denied any bowel or bladder symptoms and asked to be seen in person.

9. The Practice arranged a face-to-face appointment on the same day. At the appointment, Mrs H discussed a change of treatment with the GP. The GP suggested a H. pylori test. This was to be carried out two weeks later as one of the medications Mrs H was taking needed to be stopped at least two weeks before the test.

10. On 10 July 2021, Mrs H delivered her stool sample for the H. pylori test.

11. On 14 July 2021, the H. pylori test came back positive.

12. On 19 July 2021, the GP discussed Mrs H’s H. pylori results with her at the Practice and she began treatment.

13. On 28 July 2021, Mrs H had another conversation with the Practice doctor about her ongoing symptoms. She reported weight loss and refused support from a dietician. She was upset that she was making a number of hospital visits and felt her pain was not improving. The Practice doctor offered to refer her to gastroenterology services. Mrs H agreed to this but confirmed that if her symptoms settled before her appointment date she may cancel the referral.

14. On 6 August 2021, the Practice doctor spoke to Mrs A about concerns about Mrs H’s weight loss, ongoing abdominal pain, reduced food intake and the fact that pain relief was not helping much. The Practice completed a two-week, fast-track cancer referral to the gastroenterology department.

15. On 13 August 2021, Mrs H saw the Practice doctor, who advised that Mrs H should be admitted to hospital because of her persistent symptoms. Mrs H did not agree to this. The Practice visited Mrs H that evening to encourage her to go to hospital.

16. On 20 August 2021, a telephone consultation took place between a gastroenterologist and Mrs H. The gastroenterologist arranged an urgent gastroscopy for her.

17. On 24 August 2021, the Practice visited Mrs H to ask about her health.

18. On 28 August 2021, Mrs H went to the endoscopy unit. Her blood sugar level was low and she went to the hospital’s A&E department. Mrs H underwent blood tests including a full blood count and liver function test. The results were normal. The A&E report did not suggest infection or sepsis.

19. In September 2021, Mrs H sadly died.

Local resolution meeting

21. On 31 October 2022, we held a telephone discussion with Mrs A to discuss her complaint further, after initially reading her complaint form and response from the Practice.

22. We discussed the issues Mrs A had experienced. She said the Practice had not answered all the parts of the complaint she had initially raised.

23. Due to the unanswered complaint, Mrs A said she felt the only option to gain closure was to complain to us.

24. We discussed the outcomes Mrs A wanted. Mrs A said she just wanted the Practice to listen to what she had to say, provide her with answers, learn from the events and prevent other people from going through what she had experienced.

25. The Practice did not cover the points Mrs A had initially raised in her complaint in the correspondence we have seen. It provided her with a list of patient contacts and appointments that Mrs H had attended. It did not respond directly to the questions Mrs A had raised.

26. As the Practice had not answered Mrs A’s questions, the complaint was not yet ready for us to look at. We agreed to contact the Practice to get a more detailed response.

27. On 4 November 2022, we contacted the Practice via email. The Practice manager acknowledged the request on 7 November 2022 and sent a response to Mrs A on 15 December 2022. It offered her the opportunity to meet clinicians at the Practice and discuss her complaint in more detail.

28. Mrs A agreed to a local resolution meeting.

29. We contacted the Practice manager on 16 December 2022 to help arrange a local resolution meeting. The Practice manager agreed to hold the meeting at the Practice to discuss Mrs A’s complaint.

30. On 23 January 2023, Mrs A attended the local resolution meeting at the Practice. She told us by email the following day that she was satisfied with the outcome of the meeting. She had found closure on the concerns she had initially raised with the Practice.

Resolution

31. As a further outcome of Mrs A’s local resolution meeting, the Practice has agreed to improve its communication with patients and families and to carry out an annual audit.

32. We are pleased that we have been able to achieve the outcomes Mrs A wanted and we feel this resolves the outstanding issues in Mrs A’s complaint.

Summary

33. We do not underestimate how this experience has affected Mrs A and her family. We hope we have been able to provide some reassurance and we feel the resolution addresses the aspects of the complaint that had caused an impact. We hope we have explained our decision clearly.

34. When we consider a complaint, we think carefully about what the best options are for us to resolve it. Sometimes we can achieve a resolution without needing to do a detailed investigation and we are pleased we have been able to achieve the outcome Mrs A wanted to resolve this case.

1. We have carefully considered Mrs A’s complaint about a practice in the Calderdale area (the Practice). We do not underestimate how difficult things have been for Mrs A and her family.

2. The Practice had not addressed all the parts of Mrs A’s complaint or provided a suitable outcome for Mrs A, so we asked whether it would be willing to do this. It has agreed, and we consider this is an appropriate way to resolve Mrs A’s complaint.

3. We will explain this in more detail further below.