14. Before we decide if we should carry out 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 something has gone wrong.
GP assessment on 4 September 2021
15. Mrs I complains about the standard of care her mother received on 4 September 2021. In her complaint form, she tells us she felt the GP did not carry out a ‘full, thorough and holistic [taking account of overall health rather than just individual symptoms] examination’ of her mother. In particular, she says the GP did not carry out a temperature or oxygen saturation check and ‘should have taken more time and care’ during the examination. Mrs I says had they done so, her mother could have been admitted to A&E earlier and her sepsis, peritonitis and perforated colon could have been diagnosed and treated sooner.
16. We recognise it must be very worrying and upsetting for Mrs I to have concerns about the standard of care her mother received during this appointment. We are sorry to hear this has continued to cause her and her family long-term distress. We do not underestimate how difficult it must have been for her to relive these events and explain her complaint to us. We thank her for the time and effort she has taken to do so.
17. It is first helpful to explain the symptoms of a perforated colon peritonitis, and sepsis. Gastrointestinal perforation (GP) happens when a hole forms all the way through the stomach, large bowel or small intestine. In this case, Reverend M was diagnosed with a perforation to her colon (large intestine). The perforation can cause peritonitis, which is an infection in the inner lining of the digestive system.
18. According to the NHS advice page for peritonitis (October 2020), when a patient suffers injury or damage to the digestive system and develops peritonitis, they will typically have the following symptoms:
• sudden stomach pain that gets worse when touched or when they move • a very high temperature (the patient may feel hot and shivery) • a rapid heartbeat (the heart is beating more quickly than normal) • not being able to pass urine or passing urine much less than normal • a lack of appetite and may feel or be sick, and/or • a swollen abdomen.
19. The NICE guidance sets out the typical symptoms of a patient with sepsis. They include:
• raised respiratory rate • a blood pressure reading 40 mmHg (mm of mercury) or more below normal • a high temperature (above 36 ºC), and • a mottled or ashen appearance to the skin.
20. We have carefully considered what should have happened during Reverend M’s examination. Paragraph 15 of the GMC guidance says clinicians have a duty to ‘provide a good standard of practice and care’. When assessing or treating a patient, the clinician should ‘adequately assess the patient’s conditions’ and ‘take account of their clinical history’. The clinician should also ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’ and ‘refer a patient to another practitioner when this serves the patient’s needs’.
21. In this case, our adviser says the clinical records show the GP carried out a detailed assessment of Reverend M’s symptoms and clinical history.
22. The records show the GP considered Reverend M’s abdominal symptoms. They noted she had previously felt constipated, but had ‘passed a normal bowel movement that [morning]’ and her ‘pain had resolved’. They also documented she was ‘eating and drinking normally’, had no history of vomiting and her ‘bowel and urine’ movements were normal. On examination, her abdomen was ‘still bloated’ and distended (swollen) to touch.
23. The GP noted Reverend M was ‘hyperventilating’ (had rapid breathing) at the start of the appointment. But as the examination continued her breathing slowed and returned to a normal rate. Importantly, the records also show the GP did an oxygen saturation test. The result was within the normal range at 98% (anything above 93% is considered normal). The GP also noted Reverend M’s temperature was normal (36 ºC ). At the end of the consultation, the GP reassured Reverend M and advised her to see her GP, call 111 (an NHS phone service for getting urgent healthcare advice) or go straight to A&E if her condition worsened.
24. Taking all this into account, it appears the GP acted in line with GMC guidance. They carried out an ‘adequate assessment’ of Reverend M’s condition by considering all her symptoms and clinical history. They also quickly examined and investigated her symptoms by carrying out the relevant temperature and oxygen saturation checks.
25. The evidence shows Reverend M did not have typical symptoms of a perforated colon, sepsis or peritonitis. Her abdominal pain is not recorded as severe or worse when touched. She did not appear to have a raised temperature and her oxygen saturation levels were normal. She had no history of nausea or vomiting and had normal bowel movements. There is also no record of her presenting with pale or ashen skin. While Reverend M was breathing rapidly at the start of the appointment, her breathing slowed and returned to normal. So, it appears she did not have ongoing breathing difficulties. For all these reasons, we are satisfied the GP did not miss an opportunity to identify symptoms of the perforation, sepsis or peritonitis during this appointment.
Conduct of the GP
26. In her complaint form, Mrs I tells us she is unhappy with the GP’s conduct during the appointment on 4 September 2021. Specifically, she says the GP ‘did not adapt [their] manner’ to meet the needs of her mother, who had Alzheimer’s (a type of brain disorder affecting memory, thinking and behaviour). Mrs I also feels the GP used inappropriate humour and had a poor ‘bedside manner’ during the appointment.
27. We are sorry to hear Mrs I and her mother felt uncomfortable when they communicated with the GP during this appointment. We appreciate this must have caused them added stress at what was already a challenging and upsetting time.
28. Section five of our principles say when things have gone wrong, we expect organisations to ‘put things right’. This includes to consider offering ‘all forms of remedy’ such as an ‘apology, explanation and remedial action’.
29. On 16 March 2022, the Trust apologised to Mrs I for the GP’s conduct. The GP has reflected on their behaviour and accepted they ‘went too far’ in their attempts to put Reverend M at ease. The GP has also offered their ‘sincere apologies’ for the upset this caused.
30. By bringing this complaint to us, Mrs I wanted an acceptance of failings. We can see from the Trust’s response, the GP concerned has already formally accepted and apologised for the poor impression they made during the appointment. This is in line with our principles. So, we are satisfied the Trust has already taken appropriate steps to put this part of the complaint right.