A practice in the Wigan area

7. Mr E complains that the Practice failed to appropriately assess and take action on his father, Mr D’s, symptoms in the months prior to his death in June 2022. Mr E says his father presented with severe back and neck pain and weight loss, but his symptoms were dismissed as arthritis and a vitamin D deficiency.

8. Mr D eventually attended the Emergency Department of a local hospital, which undertook tests that revealed he had severe metastatic cancer that had destroyed part of the bone in his shoulder and had also metastasised throughout his body. He sadly died less than 24-hours after the cancer was discovered. Mr E says that the Practice’s failings meant that his father lost the opportunity for treatment options that could have prolonged his life and he suffered unnecessarily during his final months of life. This was incredibly distressing for Mr E and his family.

9. Mr E also complains that the Practice failed to respond to his complaint appropriately and initially refused to provide any details of the care provided, citing GDPR and patient confidentiality. He adds that when he challenged the Practice, it eventually provided some medical records for his father, but did not directly respond to the concerns he had raised. He also complains that the Practice refused to provide a face-to-face meeting to discuss his concerns about his father’s care.

10. He says this compounded the distress caused by the Practice’s failings.

11. Mr E would like the Practice to acknowledge what went wrong and apologise for the impact this had. He would also like it to improve its service to prevent the same failings happening again. In addition, he would like the Practice to compensate his family for the distress caused by the failings in his father’s care.

12. Mr D was a gentleman his in early 80s in 2022, when he was diagnosed with and died from metastatic lung cancer. The diagnosis came as a shock to Mr E and his family and he, sadly, died within 24 hours of this diagnosis.

13. Prior to his death, Mr D approached GPs at the Practice on several occasions to report ongoing pain, weight loss and low mood. Upon diagnosis of his lung cancer, the clinicians found that the cancer had metastasised to his bones and begun to erode his shoulder bone and compress his spinal cord.

14. Mr D’s medical records reflect that he first spoke with a GP at the Practice on 11 April 2022. He had several follow-up appointments between 26 April and 8 June, where the GPs explored a working diagnosis of Polymyalgia Rhuematica (PMR).

15. Mr D attended the ED of a local hospital on 13 June because the pain had become unbearable. Tests revealed that he had extensive metastatic lung cancer. Metastatic cancer is where the cancer has spread from the original site, in this case the lungs, to other parts of the body such as the lymph nodes and bones. Mr D died 24 hours after receiving this diagnosis.

16. Following his death, his family had questions about the care provided by the Practice. Mr D’s son, Mr E, raised a complaint on 13 July. The Practice responded on 10 August but did not provide a detailed explanation of the care provided and why. It later provided Mr D’s medical records to the family, but declined to meet with them to discuss their concerns, and did not provide a substantive written response.

Assessment and management of symptoms 20. Mr E complains the Practice failed to appropriately assess and act on his father’s symptoms in the months prior to his death in June 2022. He adds the Practice dismissed his serious symptoms as arthritis and a vitamin D deficiency.

21. We asked our GP adviser what should have happened when Mr D approached the Practice between April and June 2022. They explained that the doctors should have assessed and treated Mr D in line with the GMC’s Good Medical Practice guidance and the relevant national guidance for the GPs’ working diagnosis, which is the clinical knowledge summary for PMR published by NICE.

22. In line with section 15 of the GMC’s Good Medical Practice guidance, the GPs should have adequately assessed Mr D’s condition(s) by taking account of the history, his views and, where necessary, examining him. The GPs should also have promptly arranged suitable advice, investigations or treatment where necessary and referred him to another practitioner if this was required.

23. Mr D first approached the Practice with symptoms of musculoskeletal pain on 11 April and had a telephone consultation that day. During this telephone consultation the GP took a history of his symptoms and documented he had been in pain for three weeks, was walking with a limp, and had reduced mobility in all his joints. The GP noted his impression was that it may be osteoarthritis or rheumatoid arthritis, which are conditions that cause pain and inflammation in the joints. This assessment was in line with section 15 of the GMC’s Good Medical Practice guidance.

24. The GP also prescribed pain relief and requested blood tests to investigate his symptoms further. This was in line with the GMC’s Good Medical Practice guidance because the GP promptly referred Mr D for further investigations and provided appropriate treatment for his pain.

25. Mr D’s blood test results revealed the following:

• raised C-reactive protein (CRP) (inflammatory marker) • slightly lowered creatinine (waste product) and sodium (important electrolyte) • raised white cell count (indicator of infection) • low red blood cell count and haematocrit (proportion of red cells in blood) • increased erythrocyte sedimentation rate (ESR) (how long it takes red blood cells to settle to the bottom of a test tube).

26. Our GP adviser explained these blood results would not indicate cancer. NICE Guideline NG12 (suspected cancer: recognition and referral) comprehensively sets out the blood test results and accompanying symptoms that indicate further investigations for cancer are required. Mr D had none of the blood test result and symptom combinations that would indicate he may need further investigations for cancer.

27. Mr D spoke to a GP over the telephone on 26 April. The GP discussed his low vitamin D levels and ongoing pain. They prescribed a vitamin D supplement and a topical analgesic (pain relief that is applied to the skin). This consultation was not in line with the GMC’s Good Medical Practice guidance because the GP did not document a discussion of the other abnormal blood test results and what these might mean. Mr D’s blood results indicated increased inflammation and the GP should have explored this further during this consultation. Not addressing this in the consultation fell short of the GMC’s Good Medical Practice guidance and was a failing.

28. Mr D had another consultation with a GP at the Practice on 4 May. This consultation was face-to-face. During this consultation the GP examined him and established a working diagnosis of PMR based on his symptoms. According to the NICE clinical knowledge summary for PMR, GPs should suspect PMR when a person is over 50 years old and presents with the core symptoms of:

• bilateral shoulder pain (pain in both shoulders, though the guidance notes this can begin in one shoulder before affecting both) • stiffness in the mornings for at least 45 minutes.

29. PMR can also present with the following features:

• low grade fever • fatigue • anorexia (loss of appetite) • weight loss • depression.

30. Mr D presented with these core symptoms when he approached his GP.

31. The clinical knowledge summary from NICE also states that raised inflammatory markers in the blood support a diagnosis of PMR. We know that D had raised CRP and ESR, both of which indicate inflammation.

32. The clinical knowledge summary also states that cancer and infection should be ruled out. As there were no red flag symptoms or biological markers in his blood tests that would have alerted the GP to cancer being behind Mr D’s symptoms, there was nothing at this stage to indicate that more needed to be done to rule out cancer.

33. PMR was a working diagnosis which fit Mr D’s symptoms and blood test results. At this stage, there was nothing to indicate he had cancer, and it was appropriate to explore this working diagnosis. To do this, the GP needed to trial treatment with steroids. The GP documented a plan to prescribe steroids but did not process the prescription. This was not in line with the GMC’s Good Medical Practice guidance, which states that doctors should arrange appropriate treatment promptly.

34. Furthermore, in a nurse consultation on 10 May, the nurse documented that Mr D was unaware of the steroid prescription and did not recall the GP telling him about this plan. The nurse arranged for Mr D to see the GP again so that this prescription could be actioned.

35. It is possible Mr D forgot about this, and the Practice says this is most likely what happened. However, there is no evidence Mr D was forgetful or that he struggled retain information given to him by the Practice on any other occasions. The Practice also says the appointment was 26 minutes long and the documentation indicates this was explained to him. However, nothing in these notes confirms whether or this plan had been communicated to Mr D. It would be unusual for a gentleman with no documented memory problems to forget such an important aspect of the conversation. We also note that the prescription was never issued following the appointment, which indicates something did not progress as expected during the consultation. Our view, balancing the evidence, is that it is more likely than not Mr D was not given this information, in a way that he could understand, during this appointment.

36. The evidence reflects the communication during the consultation of 4 May was not in line with the GMC’s Good Medical Practice guidance, which states that doctors must give patients the information they want and need to know in a way they can understand. Mr D needed to know that the GP was going to prescribe steroids and why. This fell short of the GMC’s Good Medical Practice guidance and was a failing in his care.

37. In addition, the proposed plan documented by the GP on 4 May was not in line with the NICE clinical knowledge summary for PMR. This is because the plan was to review Mr D in three weeks’ time; however, the guidelines state that this review should have been arranged for one week later. This was because Mr D was being prescribed a new course of steroid medication. This was a further failing in his care.

38. On 12 May Mr D attended a face-to-face appointment at the Practice again, as recommended during his appointment with the nurse. He attended this appointment due to the previous GP not issuing the prescription for steroids. During this appointment the GP actioned the steroid prescription and arranged a follow up appointment for him. This should have taken place within one week, as per the NICE clinical knowledge summary on PMR; however, it was booked for 13 days later. This fell short of the national guidance.

39. Mr D attended the Practice again on 25 May for a review of his symptoms and the trial of steroids. At this review, he told the GP he had experienced no relief or improvement from taking the steroid medication. The NICE clinical knowledge summary indicates this should have prompted the GP to review the working diagnosis of PMR. This is because Mr D had experienced no relief from the treatment for PMR. There is no evidence the GP reconsidered the working diagnosis at this time.

40. The NICE clinical knowledge summary is unclear with regards to what clinicians should do when a person experiences no relief from the steroid treatment; however, it does state that if a person reports a less than 70% improvement in symptoms after the first week of treatment, the clinician should increase the dose of steroids. The guidance also states that if the symptoms have not settled, the doctor should review the diagnosis and consider seeking specialist advice from secondary care services. The GP did not increase Mr D’s dose of steroids during this appointment, nor did they document a rationale as to why this had not happened. They also did not consider seeking further advice or document any reconsideration of the diagnosis. This fell so far short of the NICE clinical knowledge summary for PMR and the GMC’s Good Medical Practice guidance that it was a failing in Mr D’s care.

41. The GP also referred Mr D for an X-ray of his shoulder during this consultation. Mr D’s symptoms were most pronounced in his left shoulder, but the X-ray was requested for his right shoulder. It is unclear why this happened; however, the Practice says this was likely due to human error.

42. Mr D attended the Practice again on 8 June. The GP decided to stop his steroid prescription as there had been no effect despite taking them for three weeks. The GP also requested blood tests. This was not in line with the NICE clinical knowledge summary for PMR. At this stage, it should have been clear the treatment for PMR was not having any effect on Mr D’s symptoms and this should have prompted the GP to reconsider the diagnosis and refer him to an appropriate secondary care service. Whilst the GP did document some potential alternative diagnoses at this stage, no appropriate referral was made. The Practice has highlighted he had been referred for an X-ray; however, this does not constitute an appropriate secondary care referral. This was a failing in the care provided to Mr D.

43. Mr D sadly, died on 15 June before further investigations could be carried out by his GP.

44. There were no red flag symptoms in Mr D’s presentation to alert the GPs that cancer was behind his symptoms. His presentation was highly unusual for lung cancer, with him having no respiratory symptoms and the usual biological markers, as outlined in NICE Guideline NG12, not being present. This likely hindered the GPs in identifying that Mr D had lung cancer.

45. The initial consultation was in line with the GMC’s Good Medical Practice guidance and the working diagnosis of PMR aligned with the symptoms and blood test results Mr D had. However, the GPs:

• delayed in issuing the prescription for steroids • communicated poorly with Mr D about the proposed treatment plan during the consultation of 4 May • did not follow the NICE clinical knowledge summary for the timing of reviews • failed to increase the dose of steroids when Mr D did not respond to the treatment • should have reconsidered the working diagnosis of PMR sooner • failed to refer Mr D to another practitioner, in line with the NICE guidelines, when his symptoms did not improve.

46. These errors and omissions amount to failings in the care provided to Mr D. We do not consider the Practice dismissed his symptoms, as we can see the GPs were actively treating Mr D for PMR and this was a diagnosis that could have fit his symptoms. However, the care provided was not in line with the GMC’s Good Medical Practice guidance, nor the NICE clinical knowledge summary for PMR. We have considered the impact this had below.

47. Our GP adviser explained that, with the benefit of hindsight, Mr D was more likely than not experiencing metastatic pains when he first presented at the Practice on 11 April. This is because it would be highly unusual for him to develop lung cancer and for it to metastasise so extensively over a two-month period. Had Mr D reported respiratory symptoms, this would have prompted an urgent referral for a chest X-ray under the two-week-wait pathway, as per NICE guideline NG12. However, he did not. He also did not have any of the blood test markers for cancer outlined in NICE guideline NG12. This means that any onward referrals would be non-urgent, which have a target of 18 weeks.

48. The failings identified delayed Mr D’s non-urgent referral to secondary care by several weeks. This was because of the delay in issuing the steroid prescription, the delays in undertaking reviews of the steroid medication, and the failure to consider onward referral from 25 May. We cannot know for sure exactly when he would have been referred had the delays not happened; however, the evidence indicates he could have been referred to secondary care from early to mid-May.

49. We consider this is the point Mr D could have been referred to secondary care because had the GP identified a working diagnosis in the appointment of 26 April, they could have commenced the trial of steroid medication at that time. If, in line with the NICE clinical knowledge summary, the Practice had commenced this medication and reviewed Mr D one week later and noted no improvement, it would have been in line with the NICE guidelines to increase to dose and review him again the following week. If at this point his symptoms had not improved, the GP should then have reconsidered the working diagnosis and referred Mr D to secondary care rheumatology services. This means a referral would more likely than not have been indicated from early to mid-May.

50. NHS England’s data on referral to treatment waiting times for May 2022 indicates that the average wait time for a patient referred to rheumatology services was 4.1 weeks in Mr D’s local area. This period of time reflects how long the average person waited from referral by primary care (including referrals from GP Practices) to when they were seen by secondary care services. This indicates that had Mr D been referred to rheumatology in early to mid-May, he more likely than not could have seen a rheumatologist in early to mid-June.

51. We asked our rheumatologist adviser what more likely than not would have happened had Mr D been seen by the rheumatology service prior to his admission to hospital on 13 June. They explained that, in line with the British Society for Rheumatology’s guidelines, the rheumatology service would have needed to rule out cancer given Mr D’s poor response to steroid treatment and systemic symptom of weight loss. This would likely have included a chest X-ray and/or CT scan, which could have revealed Mr D’s cancer.

52. Further investigations, such as CT scans, have a national target of being completed within six weeks. The median average wait time for CT scans in England in June 2022 was two weeks. There is no data available that is specific to Mr D’s local area. This indicates that had he been seen by rheumatology services in early to mid-June 2022 and referred for further tests, the point at which his cancer was identified would likely have been the same. Therefore, it is more likely than not that even if the GPs had followed all the national guidance, he would not have been able to complete the further tests to identify his cancer before he died on 15 June.

53. Because it is more likely than not Mr D could not have had the investigations required to diagnose his cancer before mid-June, we cannot say that he lost the opportunity for treatment options that could have prolonged his life, nor was there the opportunity for palliative care options to manage his pain and discomfort. We do think, however, that the fact Mr D’s care was not in line with the national guidance will likely be distressing for his family. This is an injustice to them that the Practice has not yet put right. We have outlined what we are asking the Practice to do to put things right later in our report.

Complaint handling 54. Mr E complains that the Practice failed to respond to his complaint appropriately and initially refused to provide any details of the care provided, citing GDPR and patient confidentiality.

55. He adds that when he challenged the Practice, it eventually provided some medical records for his father, but did not directly respond to the concerns he had raised. He also complains that the Practice refused to provide a face-to-face meeting to discuss his concerns about his father’s care.

56. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the Complaints Regulations) place a legal duty on NHS service providers, including independent providers such as the Practice, to make arrangements for dealing with complaints that ensure they are properly investigated, complainants are treated with respect, and complainants receive a timely and appropriate response. The Complaints Regulations are clear that where a person has died, a complaint can be made by a person acting on behalf of the deceased.

57. As per these regulations, NHS service providers must:

• make a written record of the complaint and provide a copy of this to the complainant • acknowledge the complaint within three working days • offer to discuss the complaint with the person to explain how it will be investigated and how long this will likely take • if a person declines to discuss the above, the provider must write to them to advise how long the complaint will take to investigate • keep the person updated during the investigation, so far as reasonably practicable • issue a report that explains how the complaint has been considered and how it reached the conclusions made.

58. The Standard General Medical Service Contract from January 2022 states that the contractor (the Practice) must establish and operate a complaints process that complies with the Complaints Regulations.

59. Our NHS Complaints Standards also provide a framework for NHS services as to what good complaint handling looks like. In line with these, the Practice should have:

• given open and honest responses as quickly as possible • ensured Mr E could see what they had done to look into the issues in a fair and objective way, based on facts • given a fair and accountable response that set out what happened and whether any mistakes were made.

60. Mr E raised a complaint on 13 July. This complaint outlined that he and his family were unhappy with the care his father received prior to his death, and that they felt this caused his father a lot of suffering before he died.

61. The Practice acknowledged the complaint the same day, which was in line with the Complaints Regulations. Mr E says, in a response to the Practice, that he did not receive the letter until two weeks later because it had not been posted until 22 July. We have not seen the postmarked envelope for this letter, but if this was not posted within three working days then this would not be in line with the Complaints Regulations. The Practice says it posted the letter the same day it was written.

62. In its acknowledgement letter, the Practice invited Mr E to contact its complaints lead by email with more details and they would then investigate the complaint. At this stage the Practice should have offered to discuss the complaint with Mr E but failed to do so. This fell short of the Complaints Regulations.

63. Mr E sent a reply by email, on 1 August, to request all correspondence be kept to letters as that is what they had been advised to do. At this stage, the Practice should have replied to Mr E, in writing, outlining how long they anticipated the investigation would take. This did not happen, which was not in line with the Complaints Regulations.

64. The Practice’s timeline for the complaint indicates that it requested the documents from Mr E’s admission to hospital in June and commenced the investigation on 2 August. It then issued a written response on 10 August.

65. The response of 10 August stated that the Practice’s lead GP felt that Mr D’s care was managed in line with NICE guidelines and onward referrals were progressed as clinically appropriate. It also said it could not provide any specific details or further information due to GDPR and patient confidentiality.

66. The response failed to explain how the complaint had been considered and how it reached the conclusions made, as required by the Complaints Regulations. It also failed to meet the standards set out in our NHS Complaints Standards, which state that responses should provide open and honest information and allow the complainant to see what the Practice did to look into the issues. The response was also not a fair and accountable response that set out what happened and why this meant the Practice felt it had not made any mistakes. This response fell so far short of the Complaints Regulations and our NHS Complaints Standards that it was a failing in the service provided to Mr E and his family.

67. The response was also inaccurate, stating it could not share information due to GDPR and patient confidentiality. GDPR is a commonly used acronym for the General Data Protection Regulations, the provisions of which are outlined in the Data Protection Act 2018. Section 3(3) of this Act is clear that this law only applies to ‘an identifiable living individual’. As Mr D was deceased when his family raised the complaint, GDPR did not apply to his medical records.

68. Whilst there is a common law duty to maintain patient confidentiality after the death of an individual, the British Medical Association’s Confidentiality Toolkit is clear that this needs to be balanced with the interests of justice and the interests of those close to the deceased person. Further, this guidance outlines that those representing the deceased, such as Mr E was in this complaint, have a statutory right to access information within the deceased’s records. The decision not to share the details of Mr D’s care, therefore, was not appropriate and the rationale for doing so was not in line with the confidentiality guidance set out by the British Medical Association.

69. Further, this complaint response asserted that all care had been in line with NICE guidelines. It failed to specify which guideline(s) it was referring to and, for the reasons outlined earlier in our report, this was not correct. The evidence we have seen so far shows that Mr D’s overall care was not in line with the NICE guidelines for PMR.

70. This complaint response was not in line with the Complaints Regulations, our NHS Complaints Standards, nor the confidentiality guidance published by the British Medical Association.

71. Mr E was very unhappy with this response and approached our service that same month. We told him we needed more information because the response from the Practice did not contain any information about his father’s care or how it had considered the complaint.

72. Mr E contacted the Practice on 18 January 2023 and asked for further information so that he could ask us for an independent review of his father’s care. It replied on 24 January 2024 to ask him to complete a Subject Access Request (SAR). Whilst this is technically not the correct procedure to process requests for the records of deceased individuals, it is common for services to use the SAR process for such requests as it is often easier and more practicable to use an existing framework to action these requests. We would not seek to criticise an organisation for using this existing framework, so long as it did not unreasonably disadvantage the person requesting the records.

73. On 24 February, Mr E approached our service again for a review of his complaint. On 3 March, we advised him we needed the Practice to provide further details in a complaint response, or confirm it was declining to do so. We documented that this was because of the serious nature of the complaint and that we needed to give the Practice the opportunity to resolve this first, which is a requirement of the Health Service Commissioners Act 1993.

74. On 9 March, Mr E raised a further complaint with the Practice. He provided much more detail as to what he was unhappy about and what he would like as an outcome to the complaint. He also asked for a meeting to discuss his concerns with the Practice’s clinical staff.

75. The Practice acknowledged this further complaint on 28 March, which fell far short of the three working days outlined in the Complaints Regulations. It also failed to provide a timeframe for when the complaint would be investigated, nor did it offer to discuss the particulars of the complaint with Mr E. This fell so far short of the Complaint Regulations that it was a failing.

76. On 27 April the Practice updated Mr E. It declined a face-to-face meeting, but did not explain why, and referenced data protection obligations in information sharing, which was incorrect. It again asked Mr E to request a SAR for his father’s medical records. This was not necessary as the Practice should, instead, have provided a written response to the complaint that outlined the care provided and how it had reached the conclusion that the care was in line with NICE guidelines.

77. Following this, Mr E contacted the Practice via telephone because the SAR form required his father’s signature. The Practice updated the form and wrote to Mr D on 5 May to advise him to return the completed form. It then provided copies of Mr D’s medical records on 15 June. It did not provide any substantive response to Mr E’s complaint, despite it disclosing his father’s medical records. This fell far short of the Complaints Regulations and our NHS Complaints Standards, and was a further failing in its complaint handling.

78. Mr E approached our service again on 30 June. We contacted the Practice directly, on 11 July, to ask whether it would be addressing Mr E’s complaint now that it had disclosed his father’s medical records. We have an obligation to ensure NHS service providers have every opportunity to address complaints first, and so we were giving the Medical Practice another opportunity to provide a substantive response to the issues raised.

79. On 18 July the Practice responded to us to say it addressed all of Mr E’s concerns in its letter dated 10 August 2022 and would not be providing a further response. This was a missed opportunity for the Practice to recognise the shortfalls in its prior responses and issue a response that was in line with the Complaint Regulations and our NHS Complaint Standards.

80. With regards to the request for a face-to-face meeting, there is no statutory duty or policy requirement for the Practice to offer this. That said, in line with our NHS Complaint Standards, the Practice should have been responsive to the needs of Mr E and his family. It should have carefully considered this request and, if it was unable to facilitate a face-to-face meeting, it should have explained why. We do not think that declining the face-to-face meeting fell so far short of our NHS Complaint Standards that it was a failing; however, the Practice should reflect on the value of such meetings, how it considers such requests, and the importance of explaining why when it cannot offer a meeting.

81. We have found that the Practice failed to administer Mr E’s complaint in line with the Complaints Regulations and our NHS Complaints Standards. We are particularly concerned that the Practice’s responses to Mr E indicate it:

• is not aware of its contractual obligations to process complaints in line with the Complaints Regulations • does not understand that GDPR does not apply to the medical records of deceased patients, nor that it is aware that individuals who are representing a deceased person have a statutory right to access the healthcare records of the deceased.

82. The complaint handling in this case fell so far short of the Complaint Regulations and our NHS Complaint Standards that it amounts to service failure.

83. Mr E says the failings in the Practice’s complaint handling compounded the distress caused by the failings in his father’s care. Whilst we have not found that the clinical failings had a clinical impact, these likely compounded the impact of this unexpected bereavement and caused further distress and frustration to Mr E’s family.

1. We have found that a GP practice in the Wigan area (the Practice): • delayed in issuing Mr D’s prescription for steroids following an appointment on 4 May 2022 • communicated poorly with Mr D about the proposed treatment plan during the consultation of 4 May 2022 • did not follow the NICE clinical knowledge summary for Polymyalgia Rhuematica when timing reviews of this working diagnosis • failed to increase the dose of steroids when Mr D did not respond to the prescribed treatment • failed to refer Mr D to another practitioner, in line with the NICE clinical knowledge summary for PMR, when his symptoms did not improve.

2. These omissions were failings in the care provided to Mr D.

3. Due to Mr D’s unusual clinical presentation and because of the very short timeframe between when he first presented at the Practice and when he died from lung cancer, it is more likely than not his cancer would not have been identified sooner had these failings not occurred. However, knowing Mr D’s care was not in line with the expected standards will be distressing to his family.

4. We have also found that that the Practice’s handling of the family’s complaint was very poor and was not in line with the NHS Complaint Regulations, or our NHS Complaints standards. This was also service failure.

5. The failings in complaint handling caused Mr E and his family distress, and compounded the distress caused by the unexpected death of their loved one.

6. We partly-uphold this complaint and have made recommendations at the end of this report.

84. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

85. Our principles say that public organisations should look for continuous improvement, and should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service. In line with our Principles we recommend the Practice: • write to Mr E to acknowledge the failings in his father’s care and its complaint handling, and apologise for the impact these had within four weeks of our final report.

• develop an action plan to improve its assessment, management, and appropriate onward referral of older adults with musculoskeletal pain and bring its GPs into line with national guidance. This should outline what action has been taken, by whom, and the date of completion. A copy should be provided to us and Mr E within eight weeks of our final report.

• develop an action plan to improve its complaint handling and bring this into line with the NHS Complaints Regulations and our NHS Complaints Standards. This should outline what action has been taken, by whom, and the date of completion. A copy should be provided to us and Mr E within eight weeks of our final report.

86. Our principles say that public organisations should put things right and, if possible return the person affected to the position they would have been in the poor service had not occurred. If that is not possible, they should compensate them appropriately.

87. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Following this review, we recommend that the organisation should pay £450 in recognition of the errors it made. It should contact Mr E to arrange payment within four weeks of our final report.