The Practice
Refusal to do a home visit
19. Mrs A complains Dr A refused to carry out a home visit for Mr E. Mrs A says the events caused her distress because she is concerned Dr A could have recognised Mr E needed hospital treatment sooner. Mrs A says Dr A did not carry out a thorough assessment and relied on self-reported observations from Mr E.
20. The Practice says it was following NHS guidance from March 2020 which told GPs to move to remote and telephone appointments, where possible. The Practice confirms it offered Mr E a telephone appointment in line with this guidance.
21. The records show that in mid-November 2020, a detailed telephone consultation took place, lasting 17 minutes 40 seconds.
22. We have reviewed guidance on GP telephone consultations during the COVID-19 pandemic. NHS ‘Standard operating procedure for primary care’ guidance at the time stated all appointments should initially be arranged remotely, but it does not state when a home visit should be carried out after a remote consultation.
23. GMC ‘Good medical practice’ states:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a. 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 b. promptly provide or arrange suitable advice, investigations or treatment where necessary c. refer a patient to another practitioner when this serves the patient’s needs.’
24. This means a home visit or face-to-face appointment should be done if a patient needs an examination which cannot be done remotely. In Mr E’s case, he had been unwell for a week. He did not have a fever and was not coughing. He was, however, lacking energy. On the phone call he did not seem confused or short of breath. In line with GMC guidance, Mr E did not need a face-to-face appointment at this time as he did not have a high fever, difficulty breathing or a cough.
25. Our GP adviser concluded that in line with GMC guidance, a home visit or a visit to the Practice was not necessary at the time of Mr E’s telephone consultation, as there was enough information available to show Mr E was not seriously unwell and a further examination was not needed.
26. The evidence shows the Practice acted in line with NHS guidance and GMC guidance by offering Mr E a telephone consultation in mid-November 2020 rather than a home visit or face-to-face consultation. We find no failings in Mr E being offered a telephone consultation.
Assessment
27. Mrs A says Dr A did not carry out a thorough assessment and relied on self-reported observations from Mr E.
28. The Practice says its GP carried out an appropriate assessment, working diagnosis and management plan.
29. We have listened to the telephone consultation that took place in mid-November 2020, lasting 17 minutes 40 seconds.
30. During the telephone conversation, a detailed history was taken. Mr E’s main complaint was a lack of energy for a week. He felt it was coming from his eyes, and on direct questioning he had a blocked feeling at the back of his nose, and a feeling of pressure in his sinuses when he bent forward. He was asked about fever, cough and pain and did not have these. He was asked if he was short of breath, and he replied that he was occasionally and it was ‘not too bad’. He spoke in complete sentences and was not audibly short of breath during the consultation. He was asked about his pulse and he said he had checked it and it was in the 60s.
31. Our GP adviser says this telephone consultation was detailed and in line with GMC ‘Good medical practice’ (see point 23).
32. We appreciate Mrs A’s concern that Dr A did not carry out a thorough assessment of Mr E. The evidence suggests Mr E’s assessment was carried out thoroughly at this time. Mr E was also told if his symptoms changed, or he felt any worse, to get back in touch. We find no failings in the GP’s telephone assessment of Mr E.
Misdiagnosis
33. Mrs A complains the GP missed the signs and symptoms of COVID-19 and a stroke.
34. The Practice complaint response does not address this issue, but it discussed the issue during the local complaints process, and it recorded its response in the meeting minutes.
35. In the minutes, the Practice says two days after the telephone consultation, the ambulance service took Mr E to the emergency department because he had low blood oxygen levels. They suspected he had a stroke and possibly COVID-19. Low blood oxygen levels can lead to complications in body tissue and organs.
36. The Practice says, based on the symptoms Mr E listed on the phone, there would be little need to check his blood oxygen levels. Mr E was talking well on the phone, he was not confused and he had no symptoms of shortness of breath or of a cough or any signs of respiratory distress at the time of the consultation. So, he did not, at the time, show symptoms of low blood oxygen levels.
37. BMJ guidance mentions symptoms of when to suspect COVID-19 in patients. These include breathlessness and distress. These symptoms were not recorded in Mr E’s medical records. The BMJ guidance also refers to red flags relating to COVID-19 when a patient with suspected COVID-19 should be sent to hospital.
38. Our GP adviser confirmed that although COVID-19 was not explicitly mentioned on the phone call, questions were asked about COVID-19 symptoms. Mr E confirmed he did not have any of these symptoms at this time, so COVID-19 did not need to be considered.
39. NHS stroke symptom guidance lists neurological signs and symptoms to recognise if someone is having a stroke. These include slurred speech, not being able to lift both arms and the face dropping on one side.
40. Our GP adviser says Mr E did not show any neurological signs or symptoms in line with NHS stroke symptom guidance.
41. The records and telephone consultation recording show the Practice acted in line with the above guidance.
42. We appreciate Mrs A’s concern that the GP missed the symptoms of COVID-19 and a stroke in Mr E. The evidence suggests Mr E did not show any signs or symptoms of a stroke or COVID-19. We find no failings in this part of the complaint.
The Trust
Fall prevention
43. Mrs A complains the Trust staff did not do enough to protect Mr E from falling. When giving comments to our provisional report, Mrs A said Mr E would not have been able to bypass bedrails. She explained Mr E could not reach over to his food and was too unwell to have been able to climb over the bedrails.
44. The Trust says it carried out risk assessments in relation to his fall risk on the day Mr E was admitted to hospital and two days later. The Trust says in view of the risk identified, the assessment recommended the use of bed rails, which were in place, but Mr E was able to bypass them.
45. The Trust says staff treated Mr E in a bay with a higher level of observation, where a nurse is always present. The Trust also says Mr E’s medical records show he attempted to get out of bed while the nurse was caring for another patient in the bay, behind the curtain to respect their dignity. After that, Mr E’s legs gave way and the nurse found him on the floor.
46. We have reviewed guidance on falls in older people. NICE clinical guideline [CG161] gives recommendations for assessment and prevention of falls in older people. The guideline includes a recommendation that all people over the age of 65 years who are admitted to hospital should be considered for a multifactorial assessment for their risk of falling while in hospital.
47. GOV.UK guidance states that a ‘bedrails assessment and implementation care plan’ should be completed within four hours of admission to an area, reassessment should be completed ‘weekly or sooner if the patient transfers, changes in condition or has a fall’.
48. Our nursing adviser says adequate measures were put in place to stop Mr E from falling. Our adviser was satisfied all appropriate risk assessments were completed and all preventative measures were taken to reduce his risk of falls.
49. When giving comments to our provisional report, Mrs A said there were two days when Mr E was in hospital that the bed rails were not in place. Although we would not be able to say for certain if the bed rails were left down at times, the medical records show risk assessments were completed and Mr E was under a high level of observation.
50. We do not underestimate what a difficult time this was for Mrs A and how worried she was about her father. The evidence shows the Trust acted in line with NICE guidance for fall prevention. We find no failings in Mr E's fall prevention, as the medical records and input from our adviser suggest the Trust did all it could to stop Mr E from falling.
Post-fall monitoring
51. Mrs A says clinicians did not carry out adequate investigations to make sure Mr E had not suffered a head injury after the fall.
52. The Trust says Mr E fell at 7am and its doctor reviewed him at 7.30am, concluding he had no head or spine injury. The Trust says the documentation does not suggest Mr E was injured after his fall.
53. The medical records show that after Mr E’s fall, a ‘Nursing/therapy post-fall assessment and intervention plan’ was completed at 7.30am.
54. NICE quality standard [QS86] ‘Falls in older people’ sets out:
‘Quality statement 4: Checks for injury after an inpatient fall
Quality statement Older people who fall during a hospital stay are checked for signs or symptoms of fracture and potential for spinal injury before they are moved. [2015]
Rationale When a person falls, it is important that they are assessed and examined promptly to see if they are injured. This will help to inform decisions about safe handling and ensure that any injuries are treated in a timely manner. Checks for injury should be included in a post-fall protocol that is followed for all older people who fall during a hospital stay.
Quality measures The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure Evidence of local arrangements to make sure hospitals have a post-fall protocol that includes checks for signs or symptoms of fracture and potential for spinal injury before the older person is moved.
Post-fall protocol
A post-fall protocol should include: • checks by healthcare professionals for signs or symptoms of fracture and potential for spinal injury before the patient is moved • safe manual handling methods for patients with signs or symptoms of fracture or potential for spinal injury (community hospitals and mental health units without the necessary equipment or staff expertise may be able to achieve this in collaboration with emergency services) • frequency and duration of neurological observations for all patients where head injury has occurred or cannot be excluded (for example, unwitnessed falls) based on the NICE guideline on head injury • timescales for medical examination after a fall (including fast-track assessment for patients who show signs of serious injury, are highly vulnerable to injury or have been immobilised); medical examination should be completed within a maximum of 12 hours, or 30 minutes if fast-tracked.’
55. The medical records show Mr E was seen by a junior doctor at 7.30am, shortly after the time he was found on the floor by the nursing staff. The Trust’s medical post-falls assessment and intervention plan was filled in appropriately. He was examined at that time and there was no sign he had suffered any injury as a result, including head injury.
56. The records show Mr E was noted to have been confused before falling and no increase in his level of confusion was noted afterwards. His GCS (Glasgow Coma Scale, a clinical scale used to reliably measure a person's level of consciousness after a brain injury) was recorded as 14/15m, the same as before the fall. The plan included doing hourly neurological observations and a CT head scan (computerised tomography scan – a form of X-ray examination) if his GCS dropped.
57. NICE clinical guideline [CG176] ‘Head Injury: assessment and early management’, states:
‘Criteria for performing a CT head scan
For adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified: － GCS less than 13 on initial assessment in the emergency department.
－ GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
－ Suspected open or depressed skull fracture.
－ Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).
－ Post-traumatic seizure.
－ Focal neurological deficit.
－ More than 1 episode of vomiting.’
58. Our physician adviser says if Mr E’s GCS had decreased post-fall, a CT head scan should have been considered by the clinical team to rule out internal injury. However, if he had suffered a bleed, he was not fit to have any neurosurgical intervention such as a CT scan because of the severe pneumonitis (inflammation of lung tissue) and the outcome would not have changed.
59. Our physician adviser says that unfortunately, had it been considered, Mr E was too unwell to have a CT scan to investigate the possibility of bleeding. Our physician adviser says even if a bleed had been found, no treatment could have been carried out that would have changed the sad outcome in his case.
60. The evidence suggests the Trust appropriately carried out adequate investigations to make sure Mr E had not suffered a head injury after the fall.
Hygiene needs
61. Mrs A says staff did not meet Mr E’s hygiene needs. Mrs A complains that when she went to see her father after his fall, he was laying in soiled bedding and clothing. She says when she went to hug her father, she got faeces on her glove.
62. The Trust says Mr E was very restless and agitated during the afternoon following his fall. It says a nurse gave Mr E midazolam to relieve his distress. As a result of this medication, Mr E was very sleepy. The Trust says the incontinence episode happened during this time. The Trust says its care documents show as part of the care and comfort ward round, Mr E received help with cleaning and changing his incontinence pad earlier in the afternoon at 12.45pm, before Mrs A’s visit.
63. The Trust apologises its staff did not clean Mr E in a timely manner and apologises it failed to meet its usual standards on this occasion.
64. The ‘Intentional care and comfort rounds’ documentation provided by the Trust requires checks to be completed ‘2 hourly as a minimum however a risk assessment must be undertaken to determine any change in frequency (deviation reasons must be documented in records)’.
65. Our nursing adviser says ‘intentional rounding’ is a timed, planned intervention that sets out to address fundamental elements of nursing care with a regular bedside ward round.
66. The medical records show when Mr E was checked at 10.45am, he had not been incontinent of faeces. At 12.45pm, when he was next checked, Mr E had been incontinent of faeces. The medical records show, this was the only time on the day of the fall Mr E had been incontinent and so the only time he could have been lying in soiled clothing. From the documentation provided, there is no way of knowing at what time during that two-hour period Mr E had been incontinent.
67. Our nursing adviser says as Mr E had one-to-one care in place, it is unlikely he had been lying in soiled clothing for the two-hour period.
68. We appreciate it would have been very upsetting for Mrs A to visit her father and find him lying in soiled clothing. We find no failings in this part of the complaint because, although it may have been unpleasant for him, Mr E suffered no actual harm by potentially lying in soiled clothing for a maximum of two hours.
69. We do not underestimate the challenges and upset these events have caused Mrs A. We are sorry to hear about Mr E’s death and offer Mrs A our condolences.
70. We have decided not to uphold this complaint.