A practice in the Colchester area

The Practice 5. Mrs R complains the Practice failed to identify and treat the cause of her mother’s swollen foot between December 2020 and January 2021.

6. She says there was a lost opportunity to prevent Mrs D being taken to hospital to treat peripheral arterial disease (PAD is a common condition where a build-up of fatty deposits in the arteries restricts blood supply to leg muscles). She says while in hospital Mrs D’s condition deteriorated, she got COVID-19 and sadly died.

The Ambulance Trust 7. Mrs R complains the Trust failed to take appropriate action on 6 January 2021 when called to attend to her mother.

8. She says there was a lost opportunity to transport her mother to hospital sooner and provide treatment for sepsis and PAD. She says her mother’s condition deteriorated when she was later admitted to hospital.

The Hospital Trust 9. Mrs R complains the Trust failed to identify Mrs D’s PAD when she attended the urgent treatment centre (UTC) between 27 December 2020 and early January 2021. She also complains her mother got COVID-19 while she was an inpatient because the Trust did not follow the policy, procedures and practises in place.

10. She says there was a lost opportunity to prevent her mother being hospitalised with PAD. She says while in hospital her mother’s condition deteriorated and she sadly died.

11. Mrs R says what happened has caused her sadness for the rest of her life. She wants each organisation to accept its failings, make service improvements and make a financial payment to her.

12. Mrs D went to see her GP on 23 December and explained she had caught her foot five days earlier and since then had noticed worsening pain and swelling. The Practice examined her and found she had a wound, a build-up of fluid on her foot and redness and swelling. It treated her with antibiotics.

13. Mrs D’s foot became more painful so she visited the Trust’s UTC on 27 December. The UTC treated and dressed her foot every two days until 4 January.

14. The family were concerned about Mrs D’s worsening condition so phoned the Practice on 6 January, explaining they were concerned she may have sepsis. The Practice suggested the family should call an ambulance.

15. The Ambulance Trust attended on 6 January and assessed Mrs D. The ambulance crew decided not to take Mrs D to hospital. They discussed the reasons for this decision with the family and advised them to contact the GP the next day.

16. Mrs D’s family took her to hospital on 8 January as they were concerned she was still having bad stomach pains. The Hospital Trust admitted Mrs D and a CT scan showed a bowel obstruction.

17. The Trust operated the next day and found Mrs D had an ischemic small bowel (blood flow is cut off so the intestines do not have the oxygen they need to do their job - this can cause tissue in part of the intestine to die). The Trust removed the damaged part of the bowel.

18. Mrs D was admitted to the intensive treatment unit (ITU) to recover. She was very unwell. On 22 January she tested positive for COVID-19. Mrs D’s condition continued to deteriorate, and she sadly died later that month.

The Practice 22. Mrs D attended the Practice on 23 December. Our GP adviser told us the medical practitioner treating her took a good history and gave a reasonable diagnosis of an infected blister injury, which was in line with the history Mrs D gave.

23. This was in line with GMC guidance that says, ‘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 promptly provide or arrange suitable advice, investigations or treatment where necessary’.

24. The Practice treated Mrs D with antibiotics and gave appropriate advice on contacting the surgery if the symptoms did not improve. This was in line with the NICE guidance on cellulitis (an infection of the deeper layers of skin and the underlying tissue), which says, ‘For people with Class I cellulitis (no signs of systemic toxicity and no uncontrolled comorbidities): Prescribe a high-dose oral antibiotic treatment’.

25. Our GP adviser told us there was nothing in Mrs D’s history or presentation to suggest she had PAD. The NICE guidance on PAD says to suspect this in these circumstances:

‘Suspect acute limb ischaemia when there is a sudden onset of leg pain or a sudden deterioration in claudication, associated with a loss of pulses and pallor. There may be features such as coldness and cyanosis of the limb, or loss of muscular power and sensation (these may be subtle or absent)’, and ‘Suspect chronic limb ischaemia when there is progressive development of a cramp-like pain in the calf, thigh or buttock on walking which is relieved by resting; unexplained foot or leg pain; or non-healing wounds on the lower limb.’

26. Mrs D did not present with these symptoms and there was a more likely obvious cause for the symptoms she had. For these reasons the Practice’s actions were in line with the GMC guidance to, ‘prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs. Provide effective treatments based on the best available evidence’.

27. The Trust also gave telephone advice on 6 January. This was given after the receptionist consulted with the GP and was not a formal consultation.

28. Our GP adviser said that as Mrs D’s daughter was concerned about sepsis it was reasonable for the GP to suggest for the family to call an ambulance for immediate help if needed.

29. This was in line with GMC guidance to, ‘refer a patient to another practitioner when this serves the patient’s needs’.

30. We did not see any signs of failings so we will not be taking any further action with the complaint about the Practice.

The Ambulance Trust 31. We understand why the family are concerned that the Ambulance Trust did not take Mrs D to hospital, given her very serious condition two days later.

32. We have considered whether the actions of the paramedics were in line with guidance, based on the information they knew at that time.

33. The Ambulance Trust guidance outlines the actions a paramedic must take when carrying out an assessment. This states the paramedic must carry out two sets of observations and, ‘the remainder of assessment needs to be focused on the patient’s presenting complaint to identify and rule in or out serious pathologies. This assessment must also include a social and holistic assessment of the patient’s needs’.

34. Our paramedic adviser told us the assessment was in line with this requirement. The paramedic took a history of the presenting complaint. There were no red flag symptoms and there was some evidence of the issues resolving, with no more abdominal pain and a decrease of the symptom of diarrhoea.

35. The ambulance patient record (PCR) shows the paramedic followed the steps outlined in the guidance. The paramedic took into account the fact Mrs D was due to see the nurse the next day and advised her to contact the GP. They noted she had the appropriate social and environmental support, with her son saying he could stay with her throughout the evening.

36. The crew member consulted with both Mrs D and her son and involved them in the decision making. This was in line with the NHS England guidance on shared decision making which says:

‘When formulating a management plan for a patient that may involve non conveyance and discharge, staff should share this decision making between relevant people. This will create a robust management plan that involves patients, caregivers, relevant individuals, or other healthcare professionals’.

37. The paramedic also followed the Ambulance Trust guidance in relation to this shared decision making by contacting the clinical advice line to consult with a senior practitioner. The guidance says:

‘Clinicians working for and on behalf of the Trust have access to 24/7 senior clinical support from the clinical advice line […] The clinical advice line is able to provide advice surrounding conveyance decisions’.

38. Our paramedic adviser said it would not be reasonable to expect the paramedic to suspect either sepsis or PAD from the signs, symptoms and presenting complaints Mrs D had. These did not suggest these conditions and were more likely to have a gastric cause. It was reasonable for the crew member to give safety netting advice in case Mrs D felt worse and to advise her to see her GP the next day. This was in line with the Ambulance Trust guidance that says:

‘Safety netting advice is essential to ensure that the patient (or their care giver) seeks medical assistance if their condition was to deteriorate’.

39. To conclude, the decision not to take Mrs D to hospital was in line with the guidance. Our paramedic adviser explained there was no immediate or obvious symptom to suggest this was needed at that time and Mrs D was at less risk of infection at home than she would have been in hospital.

40. For these reasons we have not seen any signs of failings in the actions of the Ambulance Trust.

The Hospital Trust 41. Mrs R explained the UTC did not identify Mrs D’s PAD when she attended. She felt that if this had been found it may have been treated sooner and prevented Mrs D from being admitted. The Trust has said it did not take pedal pulses at the UTC and this is a possible sign of a failing.

42. Our physician adviser explained pedal pulses are pulses that can be felt in the feet and can be an indicator, among other factors, of PAD.

43. The Trust should have checked these pulses to be in line with NICE guidance CG147 which says, ‘Assess people for the presence of peripheral arterial disease if they: […] have diabetes, non‑healing wounds on the legs or feet or unexplained leg pain […]’ and ‘Assess people with suspected peripheral arterial disease by […] examining the femoral, popliteal and foot pulses […]’.

44. Taking these pulses would have allowed the nurses to check whether there was a good supply of blood to Mrs D’s feet. It is possible taking the pulses would have showed a poor blood supply and this would have prompted the need for a referral and further assessment.

45. We considered if we can reach the conclusion Mrs R came to, as explained in paragraph 41. We cannot reach this conclusion for several reasons.

46. Our physician adviser says we do not know what would have been found if the nurses had taken the pulses. While it is possible they may have found poor blood supply, it is also possible they may have found poor circulation and this would not have needed further action.

47. They also explained we cannot say the reason Mrs D was admitted to hospital on 8 January was related to the issue she was being treated for at the UTC. The medical records for when she was admitted show she had an obstruction of the small bowel. This bowel obstruction was causing her symptoms. We cannot say this was secondary to PAD. It may have been a condition that developed separately. Mrs D may have needed admission for this condition regardless of what action the UTC had taken.

48. Our physician adviser went on to consider the situation, if we assume the admission was linked to her foot problem. They explained even if we assume the outcome of an examination of pedal pulses meant Mrs D had to be assessed for PAD, this would not have led to immediate treatment. The NHS website explains, ‘PAD is usually diagnosed through a physical examination by a GP, and by comparing the blood pressure in your arm and your ankle’. After this, a GP may need to refer for more tests to assess whether specialist treatment is needed. The website goes on to say, ‘Additional hospital-based tests that may be carried out include: an ultrasound scan – where sound waves are used to build up a picture of arteries in your leg. This can identify where in your arteries there are blockages or narrowed areas an angiogram – where a liquid called a contrast agent is injected into a vein in your arm. The agent shows up clearly on a CT scan or MRI scan and produces a detailed image of your arteries’.

49. It also says, ‘There's no cure for peripheral arterial disease (PAD), but lifestyle changes and medicine can help reduce the symptoms’. The NHS Constitution sets out that patients should wait no longer than 18 weeks from GP referral to treatment. Even if a GP saw Mrs D and referred her to a specialist, this would not have happened quickly.

50. The NHS England and NHS Improvement data shows, ‘The estimated average time that a patient had been waiting for a diagnostic test was 3.2 weeks at the end of January 2021’. It is likely that the process of assessment would not have been concluded in the 13-day period between Mrs D first being seen at the UTC on 27 December and her being admitted to hospital on 8 January.

51. To summarise, we cannot reach the conclusion that Mrs D’s admission to hospital could have been prevented.

52. Mrs R also complained her mother got COVID-19 while she was an inpatient because the Trust did not follow the policy, procedures and practices. We are sorry to hear that Mrs D got COVID-19 at a time when she was already so unwell. We know how upsetting this was for the family.

53. The Trust carried out a root cause analysis when Mrs D tested positive for COVID-19. This was in line with the NHS England and NHS Improvement COVID-19 guidance that says, ‘we are now asking all organisations to do root cause analyses (RCAs) for every probable healthcare associated COVID-19 inpatient infection i.e. patients diagnosed more than 7 days after admission’.

54. The root cause analysis showed probable healthcare associated COVID-19 (this is when a patient tests positive within 14 days of admission. Mrs D’s positive swab was taken on day 14). It also showed no staff on the ward had tested positive for COVID-19. We do not know how Mrs D got COVID-19, or what date this happened.

55. We cannot say Mrs D got COVID-19 due to the Trust not following the policy, procedures and practices in place.

56. We can see the Trust had a clear policy in place for what personal protective equipment (PPE) to wear in different parts of the hospital. This was in line with the UK Health Security Agency instruction that says:

‘- hospitals should ensure that measures are in place so that all settings are, where practicable, COVID-secure, using social distancing, optimal hand hygiene, frequent surface decontamination, ventilation and other measures where appropriate - in all settings that are unable to be delivered as COVID-19 secure, all hospital staff (both in clinical and non-clinical roles), when not otherwise required to use personal protective equipment, should wear a facemask; worn to prevent the spread of infection from the wearer*

- visitors and outpatients to hospital settings should wear a form of face covering for the same reason, to prevent the spread of infection from the wearer

*The recommendation is for a Type I or Type II facemask worn to prevent the spread of infection from the wearer. If Type IIR facemasks are more readily available, and there are no local supply issues for their use as personal protective equipment, then these can be used as an alternative to Type I or Type II masks.’

57. We have not seen any evidence to show this guidance was not followed.

58. The Trust carried out audits of hand hygiene and PPE compliance in all areas of the Trust. In January 2021 compliance was found to be 99.18% for hand hygiene and 99.19% for PPE. This shows clear compliance and a proactive approach by the Trust in checking this.

59. We understand why Mrs R was worried. She explained the Trust failed to take a diagnostic swab on day seven of Mrs D’s admission and she felt this was evidence of non-compliance with safety processes.

60. We cannot make the link between the failure to take a swab and Mrs D getting COVID-19 (the source of which is unknown) and we cannot conclude it was due to a failure to follow other policies and practices. As the levels of compliance show, the Trust was following the required processes.

61. For these reasons we cannot say that not doing one swab means there were wider failings that led to Mrs D getting COVID-19.

62. We know how much this complaint means to Mrs R and we thank her for bringing her concerns to our attention. We hope this report explains our thorough consideration of the issues.

1. We have carefully considered Mrs R’s complaint about the care and treatment a GP practice in the Colchester area (the Practice), East of England Ambulance Service (the Ambulance Trust) and East Suffolk and North Essex NHS Foundation Trust (the Hospital Trust) gave her mother, Mrs D, between December 2020 and January 2021.

2. We have decided not to take further action because we did not see any signs of failings with the actions of the Practice and the Ambulance Trust.

3. With the Hospital Trust, we found some signs of failings. We have decided we cannot link the events complained about to Mrs D being admitted to hospital, or her sad death.

4. We know Mrs R and her family have been deeply affected by what happened and we thank her for sharing the details with us. We recognise it is likely she will be disappointed by our decision. We hope we have clearly explained the reasons for our decision.