Death certificate
14. Mrs H says the Practice gave the incorrect information to the coroner for the cause of death. Mrs H says she was contacted by the registry office to register her father’s death. She told them she had not had the death certificate and they told her they had the information from the Practice. Mrs H says she was told the cause of death was a chest infection and due to his age.
15. Mrs H says she disagrees with this because her father did not have a chest infection. She agreed with the registry office for the coroner to complete an autopsy to discover the cause of death. The coroner reported the autopsy results to the Practice and these showed Mr O’s cause of death as ischaemic heart disease.
16. The Practice responded to Mrs H’s complaint in a letter dated 18 January 2023. It said it had time to reflect on the complaint and after reviewing the medical information the GP used to complete the death certificate, it accepted that incorrect information was given to the coroner. The Practice apologised to Mrs H and said it has an open approach when dealing with complaints and aims to learn and improve care given to its patients. It says learning points were discussed and shared with the wider team in a Practice meeting. The Practice says it is usually the GP who last saw the patient who completes the death certificate. The GP who was the last to see Mr O and completed the death certificate, sent a personal response to Mrs H on behalf of the Practice.
17. The GP says they reflected on the information they provided and they should have referred to the coroner for an autopsy. They say they can only apologise for not doing this. The GP apologised throughout the letter. They said it was unclear to them the exact cause of death at the time but, because Mr O was waiting for more investigations, they felt the cause of death was old age. They accepted the effect the incorrect cause of death had on the family and say they have taken learning from this and time to reflect on their clinical approach.
18. As an outcome Mrs H wanted the Practice to apologise for giving incorrect information to the coroner. We have seen evidence of the Practice and GP accepting responsibility and apologising. The Practice and GP says they have taken learning from this experience.
19. Our Principles say corrective action can be an apology, explanation and acknowledgement of responsibility. Our Principles also say changing procedures to stop the same thing happening again and giving learning and training to staff are appropriate solutions when things have gone wrong.
20. We are sorry to hear about Mrs H’s experience and offer our deepest condolences. We have listened to what she has said about the Practice’s actions. While the Practice has accepted the incorrect information was given to the coroner, we think it has done enough to put right this part of his complaint and we are not taking any further action.
Referral
21. Mrs H says her father did not get care and support from the Practice, it was difficult for her father to get appointments and he would see different GP’s who did not know about his medical history. We are sorry to learn that Mrs H feels her father was pushed aside and not dealt with properly.
22. We have seen evidence from the medical records between 22 August and 9 December 2022 of a total of 12 appointments (eight face to face and four telephone consultations). While patients prefer to see their usual GP, the Practice have said there would be times when different GP’s cover other patients. Mr O’s medical records include his medical history and would have been available for other GPs to see.
23. We have spoken with Mrs H to ask what more she feels the Practice should have done. She said on 5 October 2022 the Practice told her father it had submitted a two-week fast track referral to the hospital for a colorectal consultation. Mrs H is concerned the hospital did not make Mr O an appointment until mid-December and sadly by this time her father had died.
24. GMC guidance says:
‘In providing clinical care you must refer a patient to another suitably qualified practitioner when this serves their needs.’
25. Mr O’s medical records show the Practice completed a fast-track referral to the NHS digital system on 5 October. This referral was made on the urgent pathway for suspected bowel cancer. It is noted the Practice told Mr O it could take six weeks to get an appointment from the hospital.
26. Mr O got an appointment from the hospital for nine and half weeks after the Practice made the urgent referral.
27. We discussed this with Mrs H and advised her once a referral had been submitted it would be the responsibility of the hospital to arrange the appointment. We explained if she was not satisfied with the waiting time, she would need to complain directly to the hospital as this was not something the Practice could control.
28. We think the Practice acted in line with the GMC guidance in making the referral. It is sad and unfortunate that the appointment came too late to explore Mr O’s symptoms further.
29. We explained this to Mrs H and asked what more she thought the Practice could do. She told us her father had regular appointments and could not see what more the Practice could have done. We understand Mr O died suddenly and Mrs H described the active lifestyle her father had led until shortly before his illness and death. We understand this left Mrs H feeling she had unanswered questions about his care.
30. We have seen no evidence that anything went wrong with how the Practice made the referral and we are not taking action on this part of the complaint.
Home visit
31. Mrs H says she contacted the Practice in early December 2022 to ask for a home visit. She says she told the Practice her father had ongoing diarrhoea, was up many times during the night and was short of breath but did not have chest pains. The Practice arranged a home visit for the same day but advised Mrs H to call an ambulance if his condition got worse.
32. Mrs H says they were given a guide of between 12pm to 3pm for the home visit, so she stayed with her father. Mrs H says nobody from the Practice came. Mrs H says she contacted the Practice and was told the GP had already been and could not return due to other appointments. It again said to call an ambulance if Mr O got worse. Mrs H called an ambulance because she wanted to get her father checked in A&E. Mr O sadly died before the ambulance arrived.
33.Mrs H told us her family were heartbroken after his death. We can see Mr O was well loved and the situation is terribly sad.
34. The Practice records show the GP called at the house at 2.27pm on the scheduled day but there was no answer when they knocked on the window or rang the doorbell. The GP noted that they waited at the house for 15 minutes.
35. We explained to Mrs H how we have to base our decision on evidence and facts. We discussed we would be unlikely to find evidence, other than her account, to show the doctor did not come to the house. We have seen no reason to doubt the accuracy of the Practice’s records. At the same time, we have no reason to doubt Mrs H’s account that nobody called.
36. We think it is possible that Mrs H and her father did not hear when the GP called. It may be that Mrs H and her father were distracted at the time. It is unlikely that we will reach a point where we can say for certain.
37. We explained this to Mrs H who understood this as she told us it was ‘her word against theirs’.
38. We do not wish to underestimate the emotional impact this had on Mrs H. We are sorry to hear about what happened and appreciate this was a difficult and distressing time.
39. We thank Mrs H for bringing her concerns to us.